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A  PRACTICAL  TREATISE 


3453 


The  Diseases  OF  THE  Haik  AH  ^GALP 


GEORGE  THOMAS  JACKSON,  M.D. 

Professor  of  Dermatology,  Woman's  Medical  College,  N,  Y.  Infirraarj';  Chief  of  Clinic 

and  Instructor  iu  Dermatology,  College  of  Physicians  and  Surgeons;  CgusuU- 

iug  Dermatologist,  Presbyterian  Hospital ;  Visiting  Dermatologist, 

Randall's  Island  Hospital;  Member  of  the  American 

Dermatological  Association,  etc 


NEW,  REVISED,  AND  ENLARGED  EDITION 


NEW    YORK: 

E.  B.  TREAT  &  COMPANY, 

241-243  WEST  23D  STREET. 
CHICAGO:     R.  C.  TREAT,   199  Clark  Street. 


$2.00,  net. 


COPYRIGHT    r,V 

GEORGE)   THOMAS  JACKSON 

1887-1803 


PHiSS    iF    iTtrriNER,  LAKHERT  ..  CO.  .    tt,   t4  A  26   HE*0£   ST.,    NEW   YORK. 


Library 

PREFACE, 


In  this  edition  of  this  book  it  is  hoped  that  the 
reader  will  find  all  the  knowledge  about  the  hair  that 
has  been  gained  during  the  years  that  have  gone  since 
the  appearance  of  the  first  edition  of  this  book  in 
March,  1887,  During  this  time  alopecia  areata,  the 
parasitic  diseases,  and  seborrhoea  have  been  studied 
with  great  care  by  many  investigators. 

Every  page  of  the  old  edition  has  been  revised  and 
corrected  ;  new  articles  upon  folliculitis  decalvans, 
lepothrix,  and  aplasia  pilorum  propria,  and  many 
new  sections  to  the  old  chapters,  have  been  added. 
The  bibliography  has  been  brought  down  to  January, 
^  1893,  and  nine  new  illustrations  have  been  inserted  in 
K  the  text. 

\     The  author  hopes  that  the  present  edition  of  the 
>^  book  will  meet  with  as  good  a  reception  as  the  first 
^  edition  did,  and  that  it  may  prove  useful  to  his  pro 
fessional  brethren. 
14  East  31st  street,  New  York, 


624323 


PREFACE  TO  FIRST  EDITION. 

Five  years  ago,  the  author  of  this  work  was  in  need 
of  some  complete  treatise  upon  the  diseases  of  the  hair; 
and  finding  none  of  recent  date,  excepting  such  as 
were  rather  of  a  popular  than  a  scientific  character,  he 
began  those  studies  which  have  resulted  in  the  present 
volume. 

The  aim  of  this  book  is  to  present  to  the  medical  pro- 
fession a  concise  statement  of  what  is  known  of  the 
diseases  of  the  hair  and  scalp;  special  attention  being 
given  to  their  diagnosis  and  treatment.  To  this  end 
a  great  number  of  medical  journals  have  been  con- 
sulted, and  all  available  books  upon  the  hair  have  been 
read. 

The  chapter  upon  the  anatomy  of  the  hair  is  drawn 
chiefly  from  Waldeyer's  '^ Atlas  der  Menschlichen 
und  Tierischen  Haare,^^  Lahr,  1884;  and  from  Unna's 
article  upon  the  anatomy  of  the  skin  in  the  last  num- 
ber of  Ziemssen's  ''  Ilandbuch  der  speciellen  Pathologie 
und  Therapies  Leipzig,  1883.  Those  diseases  of 
the  scalp  which  occur  as  part  of  a  general  disease  of 
the  integument  have  been  described  briefly,  since  all 
text  books  on  dermatology  treat  fully  of  them. 

In  the  Journal  Literature  there  will  be  found  but 
few  references  to  papers  which  have  appeared  prior  to 


18(30.  lu  the  last  tweuty-five  years  our  kiiowledge  of 
the  diseases  of  the  hair  has  so  advanced  that  many 
of  the  views  held  by  writers  of  an  earher  date  are 
no  longer  of  practical  value.  Where  experience  has 
shown  that  the  older  writers  were  right,  their  princi- 
ples and  practice  have  been  absorbed  into  the  general 
sum  of  our  knowledge,  and  are  to  be  found  in  all  sys- 
tematic treatises  upon  the  skin.  For  these  reasons  the 
year  1860  has  been  chosen  arbitrarily  as  a  dividing  line, 
and  the  Hterature  of  the  following  years  only  has 
been  consulted.  The  Bibliography  contains  the  titles 
of  books  ^vhich  deal  solely  with  the  hair,  and  also  of 
general  treatises  upon  the  skin  which  have  been  con- 
sulted. Such  references  as  have  not  been  accessible 
to  the  author  he  has  indicated  by  grouping  them  to- 
gether and  having  them  printed  in  smaller  type. 

The  author  takes  gi-eat  pleasure  in  acknowledging 
in  this  place  his  obligations  and  expressing  his  thanks 
to  his  friends  Dr.  George  Henry  Fox  and  Dr.  Edw^ard 
B.  Bronson,  and  to  his  brother  Eev.  S.  M.  Jackson,  for 
valuable  suggestions  and  kindly  criticisms  during  the 
composition  of  this  book.  The  gi'eater  number  of  the 
illustrations  which  add  so  much  to  the  value  of  the 
work  are  from  the  large  collection  of  photogi^aphs  be- 
longing to  Dr.  George  Henry  Fox,  who  placed  them 
most  generously  at  the  author's  disposal 

No.  14  East  81st  St.,  New  York, 
March  Ut,  1887. 


CONTENTS. 


PART  I. 


General  Considerations. 

CHAP.  PAGE 

I.  Anatomy  of  the  Hair, 21 

II.  Physiology  of  the  Hair,  ....         32 

III.  Hygiene  of  the  Scalp  and  Hair. .         .        .51 

PART  II. 
Essential  Diseases  of  the  Hair. 

IV.  Canities, 63 

V.  Changes  in   the  Color  of  the  Hair  other 

than  turning  Gray,  .         .         .         .74 

VI.  Alopecia, 80 

VII.  Alopecia  Areata, 115 

VIII.  Atrophia  Pilorum  Propria,      .         .         .        140 

IX.  Hypertrophia  Pilorum,or  Hypertrichosis,  .  158 

X.  Trichiasis  and  Distichiasis,       .         .         .180 

XI.  Sycosis 182 


PART  III. 
Parasitic  Diseases  of  the  Hair. 

CHAP.  PAGE 

XII.  Trichophytosis  Capitis,    ....        205 

XIII.  Kerion, 239 

XIV.  Trichophytosis  Barbae,    ....        245 
XV.  Favus, .         .256 

XVI.  Pediculosis  Capitis,  .        .        .        .        275 

XVII.  ''  Pubis, 283 

XVIII.  Beigel's  Disease,  and  other  unusual  para- 
sitic Diseases.  ....        290 


PART  IV. 

Diseases    of    the    Hair    secondary    to    Diseases 
OF  THE  Skin. 

XIX.  Dandruff, '    .  .299 

XX.  Keratosis  Pilaris, 310 

XXI.  Eczema  Capitis  et  Barbae,          .        .  .314 

XXII.  PUca  Polonica, 339 

XXIII.  Dermatitis  Papillaris  CapiUitii,           .  .  344 

XXIV.  Naevus  Pilosus, 350 

XXV.  Syphihs.    Lupus.     Vitihgo.       .        .  .354 


Bibhography  and  Journal  Literature,          .         .       365 
Index, i09 


CHAPTER  I. 

ANATOMY   OF  THE   HAIR. 

Before  we  can  understand  the  diseases  which  affect 
the  hair,  it  is  necessary  for  us  to  have  some  knowledge 
of  its  anatomy  and  physiology.  The  close  connection 
of  the  sebaceous  glands  with  the  hair  foUicles,  and  the 
fact  that  disease  of  the  former  is  very  commonly  asso- 
ciated with  that  of  the  latter,  render  it  essential  for  us 
to  devote  a  little  time  to  the  anatomy  and  functions  of 
these  glands.  It  is  true  that  histologists  are  not  yet 
in  perfect  accord  in  regard  to  some  points  in  the  micro- 
scopical anatomy  of  the  hair,  and  that  there  are  yet 
some  unanswered  questions  in  the  phenomena  of  its 
development  J  growth,  fall  and  regeneration;  but,  nev- 
ertheless, we  know  enough  to  aid  us  materially  in  our 
study  of  its  diseases. 

General  Description. — The  hair  is  an  epidermic 
structure  consisting  of  a  root,  which  is  seated  in  the 
skin  and  expanded  below  to  form  the  hulh;  and  of  a 
shaft,  which  projects  beyond  the  surface  of  the  skin 
and  terminates  in  Si  point.  Its  form  may  be  described 
as  spindle-shaped,  or  as  a  slender  cone  gradually  taper- 
ing to  its  apex.  Its  contour  is  circular,  oval  or  flat- 
tened; and  it  is  either  straight,  or  more  or  less  curled. 
It  presents  three  main  varieties:  1.  Long,  soft  hair, 
such  as  is  met  with  on  the  head,  in  the  beard,  on  the 
pubis  and  in  the  axillae.  2.  Short,  stiff  hair,  such  as 
is  found  in  the  eyebrows  and  eyelashes.  3.  Lanugo, 
or  soft,  downy,  colorless  hair,  such  as  is  scattered  all  over 
the  surface  of  the  body,  where  the  other  varieties  are 
absent.     Each  hair  grows  from  a  small  nipple-shaped 


22  DISEASES   OF  THE   HAIR  AND  SCALP. 

connective-tissue  projection,  the  hair  papilla,  situated 
at  the  bottom  of  a  deep  slender  pocket  or  sac-like  de- 
pression in  the  skin  which  is  called  the  hair  follicle. 
To  each  hair  foUicle  there  is  attached  one  or  more  se- 
baceous glands,  which  empty  by  their  ducts  into  its 
upper  third. 

The  Hair. — The  hair  is  composed  of  three  layers, 
which  from  within  outwards  are  :  1.  The  medulla. 
2.  The  cortex.  3.  The  cuticle.  These  are  distin- 
guishable even  in  the  deepest  part  of  the  hair  root, 
and  become  yet  more  distinct  as  we  proceed  upwards. 
The  hail's,  excepting  those  called  lanugo,  are  hollow 
cylinders,  the  central  cavity  being  filled,  in  fully  formed 
healthy  hair,  with  the  medulla,  and  called  the  medul- 
lary canal.  This  canal  begins  below  at  the  papilla,  and 
extends  to  T\ithin  a  short  distance  of  the  point  of  un- 
cut hairs.  In  the  lanugo  hairs  it  is  generally  wanting. 
The  upper  extremity  or  tip  of  the  hair  is  pointed,  if 
the  hair  has  not  been  cut;  if  it  has  been  cut  it  is  flat- 
tened, or  more  or  less  rounded,  depending  upon  the 
length  of  time  that  has  intervened  between  the  time 
of  cutting  and  of  examination;  if  a  sufficient  time  has 
elapsed  it  may  even  become  again  pointed.  The  lower 
extremity  of  the  hair,  the  root,  is  expanded  to  form  the 
bulb,  which  is  hollou'ed  out  so  as  to  fit  accurately  hke  a 
cap  over  the  nipple -shaped  papilla  upon  which  it  rests. 

The  jMedulla. — The  medulla  consists  of  a  column 
of  superimposed  cells  which  occupies  the  cavity  of  the 
medullary  canal.  It  begins  immediately  upon  the 
upper  rounded  top  of  the  hair  papiUa  as  a  layer  of  ir- 
regular cubical  epithelial  cells,  each  ceU  containing  one 
or  two  masses  of  keratohyalin,  which  appear  as  dark 
round  drops.  Waldeyer  (S3)  thinks  it.  probable 
that  keratohyahn,  the  ''eleidin"  of  Raxvier,  is 
identical  with  the  "  hyahn  ''  of  Von  Eecklinghausen, 
wliich  is  found  in  many  different  kinds  of  cells.     As 


ANATOMY  OF  THE  HAIR.  23 

we  trace  the  medulla  higher  up  in  the  hair  we  see  that 
the  cells,  which  were  dispersed  at  first  irregularly  in 
layers,  form  themselves  into  a  stratified  column,  like 
a  roll  of  coins,  with  three  or  four  cells  in  each  horizon- 
tal layer.  According  to  Waldeyer  (83)  the  cells  are 
held  together  by  means  of  delicate  projections,  and 
when  isolated  appear  hke  the  prickle  cells  of  the  skin. 
The  lower  cells  alone  have  nuclei.  As  the  medulla 
ascends  in  the  hair  the  cells  become  more  and  more 
flattened,  the  keratohyalin  melts  into  the  cell  plasma, 
and  the  nucleus  shrivels  up  and  disappears.  Then  the 
cells  themselves  shrivel  and  leave  spaces  between  them, 
which  in  the  middle  follicle  region  are  filled  with  air,  so 
that  the  cells  are  surrounded  by  a  system  of  air  canals. 
The  air  does  not  penetrate  the  cells.  Towards  the  point 
of  the  hair  the  medulla  is  reduced  to  a  column  of  single 
cells  laid  one  upon  the  other.  Then  the  column  be- 
comes broken  up,  gi^eater  or  smaller  spaces  forming 
between  the  cells,  till  finally  it  ends.  The  medulla  cells 
sometimes  contain  pigment.  The  delicate  foetal  hairs 
are  without  a  medulla,  as  are  also  most  of  the  lanugo 
hairs.  As  a  rule,  the  greater  the  diameter  of  the  hair, 
the  greater  will  be  the  diameter  of  the  medulla.  Nev- 
ertheless strong  hairs  will  often  be  found  with  propor- 
tionately thin  medull^e,  as  is  frequently  the  case  in  the 
hairs  of  the  human  beard.  Still  more  common  is  it  to 
find  thin  hairs  with  stout  meduUae.  Towards  the  close 
of  the  life  limit  of  a  hair  no  more  medulla  cells  are  pro- 
duced, and  in  such  hairs  there  is  a  wide  space  between 
the  bottom  of  the  medulla  and  the  end  of  the  root. 

The  Cortex. — The  second  layer  of  the  hair  is  the 
cortical  substance.  This  is  the  substance  proper  of  the 
hair,  and  consists  of  long  spindle-shaped  epithelial  cells 
which  are  flattened  out  into  fine  bands,  and  run  in  the 
long  axis  of  the  hair.  They  are  completely  cornified 
and  contain  a  shrunken  nucleus,  which  appears  as  if 


24  DISEASES   OF  THE   HAIR   A>T)   SCALP. 

pulled  out  length^^^se;  it  is  wanting  entirely  towards 
the  point  of  the  hair,  and  is  plainly  seen  only  in  the 
root.  The  first  cells  of  the  cortex  in  the  neighborhood 
of  the  papilla  are  cube-shaped,  but  under  pressure  from 
without  inwards  they  become  as  described  above.  The 
cortical  cells  are,  hke  those  of  the  medulla,  provided 
with  prickles.  In  the  cortex  are  found  pigment  and 
air.  The  pigment  occurs  either  in  the  form  of 
gTanules,  or  diffused.  The  granular  pigment  is 
found  heaped  up  in  the  cells  of  the  cortex,  especially 
in  those  Mug  i^eripherally,  and  sometimes  the  gran- 
ules are  crowded  so  closely  together  as  to  render  the 
individual  ones  indistinguishable.  In  the  upper  part 
of  the  cortex  pigment  granules  may  be  fomid  lying 
between  the  cells.  The  diffused  pigment  is  the  essen- 
tial coloring  matter  of  the  hau\  The  air  gains  entrance 
to  the  cortex  on  account  of  a  separation  taking  place 
between  its  cells,  and  is  fomid  either  in  the  form  of 
rounded,  discrete  air-globules,  or  in  groups  of  them,  or 
in  long  streaks. 

The  Cuticle. — The  third  and  last  layer  of  the  hair 
is  the  cuticle.  It  corresponds  to  the  epidermis  of  the 
skin  in  location  and  function.  It  consists  of  flattened, 
non-nucleated,  fully  cornified  cells  which  cover  the  hair 
like  scales  and  are  arranged  hke  shingles  on  a  roof  with 
their  free  ends  du^ected  towards  the  ix)int  of  the  hair. 
In  the  lower  part  of  the  hair  root  these  ceUs  are  cyhn- 
drical  and  contain  nuclei;  but  they  gTadually  becojne 
flattened  and  lose  their  nuclei.  In  the  deej^est  part 
of  the  shaft  of  old  hairs  the  cuticle  is  wanting. 

Hair-Eoot. — The  root  of  the  hak,  with  its  bulb  or 
expanded  part,  contains  aU  the  elements  of  the  hair. 
As  the  hair  shaft  descends  towards  the  lower  part  of 
the  hair-folhcle  it  widens  more  rapidly,  and  then  swells 
out  to  form  the  bulb  Avhich  covers  like  a  cap  the  papilla, 
excepting  at  its  naiTOwest  part.     It  results  from  this 


,1 


mk 


oh 

h 


Longitudinal  Section  of  Hair  Root  from  Beard. 

OS  =  External  sheath  of  hair-follicle.  i&  =  Internal  sheath  of  hair-follicle,  gt 
—  Vitreous  membrane,  aw  =  External  root  sheath,  iw  =  Internal  root-sheath, 
fce  =  Henle's  layer.  Aw  =  Huxley ''s  layer,  ow  =  Cuticle  of  root-sheath,  oh  =• 
Cuticle  of  hair,  h  =  Cortex  of  hair,  ink  =  Medulla,  p  =  Papilla,  viiw,  mo,  mh^ 
mm  =•  Matrices  of  iw,  aw,  oh,  mk,  and  h.    ph  =  Neck  of  papilla. 


26  DISEASES   OF  THE   HAIR  AND  SCALP. 

that  the  bulb  is  hollow  below  and  indented  like  the 
bottom  of  a  champagne  bottle.  The  lower  part  of  the 
bulb  contains  the  matrices  of  the  three  layer-s  of  the 
hair.  The  matrix  of  the  medulla  occupies  the  part 
coiTesponding  to  the  top  of  the  papilla,  and  consists  of 
irregular  cubic  cells.  That  of  the  cortical  substance 
begins  at  the  side  of  the  body  of  the  papilla,  in  a  layer 
of  cyhndrical  cells;  while  that  of  the  cuticle  springs 
from  the  neck  of  the  papilla,  and  is  hkewise  composed 
of  cyhndrical  cells.  The  matrix  cells  soon  begin  to 
take  on  the  characteristics  of  the  cells  of  the  different 
layers  as  we  have  already  learned  to  know  them.  The 
sheaths  which  suiTound  the  hair  at  its  root  are  two 
in  number,  the  hair-foUicle  and  the  root-sheath.  The 
hair-foUicle  is  derived  from  the  cutis,  while  the  root- 
sheath  is  formed  from  the  epidermis.  We  may  rep- 
resent the  arrangement  of  the  hair  and  its  sheaths  by 
picturing  to  oui'selves  the  effect  of  thrusting,  let  us  say, 
a  dull  needle  into  the  skin.  First  there  will  take  place 
a  depression  of  the  whole  skin,  and  then  the  epider- 
mis will  be  punctured  at  the  lower  paii;  of  the  depres- 
sion and  the  point  ^ill  come  in  contact  \^ith  the  cutis 
below.  The  cutis  wiU  be  to  the  outside  and  represent 
the  hair-foUicle,  the  epidermis  vdU.  be  in  the  middle 
and  represent  the  root-sheath,  while  the  blunt  point 
of  the  needle  vdR  represent  the  hair-root. 

Hair-Follicle. — The  hair  foUicle  is  always  placed 
at  an  angle  to  the  skin  excepting  in  the  eyelashes, 
where  it  is  perpendicular  to  the  tarsal  edge.  It  is 
foimd  in  the  upper  half  of  the  cutis  when  it  is  con- 
nected with  lanugo  hairs;  deeper  placed  ^^ith  stronger 
hairs;  and  in  the  subcutaneous  connective  tissue  in 
comiection  vrith.  some  very  coarse  hairs;  and  is  from 
one-twelfth  to  one-foui-th  of  an  inch  deep.  It  is  a  per- 
manent structui'e,  and  does  not  leave  its  place  when  a 
hair  is  plucked  from  the  skin.     It  begins  above  at  the 


ANATOMY  OF  THE  HAlH.  27 

opening  of  the  sebaceous  gland,  passes  down  alongside 
of  the  hair,  and  surrounds  its  lower  end  forming  a 
closed  pouch,  while  some  of  its  fibres  enter  the  hair- 
root  from  below  to  form  the  papilla.  It  consists  of 
three  layers;  1.  An  outer  longitudinal  fibrous  layer  of 
ordinary  connective  tissue.  2.  A  middle  layer  of  cir- 
cular fibres  which  are  richly  studded  with  long  nuclei 
resembling  those  of  smooth  muscular  fibres;  but  no 
muscular  fibres  are  present.  This  layer  is  the  true 
foundation  of  the  follicle,  and  is  the  only  one  that  en- 
ters into  the  formation  of  the  papilla.  3.  The  vitre- 
ous membrane  which  is  inside  of  all.  It  is  a  thin, 
smooth  and  homogeneous  membrane,  which,  accord- 
ing to  Unna  (82  a),  is  merely  a  thickening  of  the  inner 
coat  of  the  middle  layer  of  the  follicle,  and  is  only 
found  in  its  lower  one  third.  The  older  the  hair  is,  the 
more  prominent  does  this  membrane  become.  The 
inside  of  this  membrane,  especially  in  old  hairs,  is 
thrown  into  circular  or  semi-circular  projections  or 
ridges,  which  protrude  into  the  prickle -cell  layer  of  the 
outer  root  sheath  in  the  form  of  variously  sized,  duU  or 
sharp-pointed  teeth.     It  does  not  reach  to  the  papiUa. 

Eoot-Sheath. — The  root-sheath  consists,  as  usually 
described,  of  two  parts,  namely:  1.  An  external  root- 
sheath.  2.  An  internal  root-sheath.  Unna  (82  a) 
teaches  that  the  external  root-sheath  should  be  desig- 
nated as  the  prickle-cell  layer  of  the  hair-follicle,  as  it 
is  genetically  different  from  the  internal  root-  sheath, 
being  continuous  with  the  epidermis;  while  the  inter- 
nal root- sheath  springs  from  the  hair  papiUa.  The  ex- 
ternal root-sheath  is  continuous  above  with  the  epider- 
mis. As  it  reaches  the  mouth  of  the  sebaceous  gland 
the  granular  and  corneous  layers  of  the  epidermis 
cease,  and  the  prickle  and  cylindrical  cell  layers  proceed 
in  full  width  to  near  the  papilla,  where  they  suddenly 
grow  smaller;  and  finally  at  the  neck  of  the  papiUa  they 


28  DISEASES  OF  THE  HAIR  AND   SCALP. 

form  a  narrow  stratum.  It  is  composed  of  three  layers : 
1.  An  external  cylindrical  cell  layer  which  is  continuous 
with  the  cylindrical  cell  layer  of  the  epidermis,  and 
like  it  is  composed  of  a  single  row  of  cells,  which  pre- 
sent their  narrow  ends  to  the  vitreous  membrane  of  the 
hair-follicle.  2.  A  middle  prickle  cell  layer,  a  continu- 
ation of  the  same  layer  of  the  epidermis.  This  is  the 
thickest  of  all  the  layers  of  the  root -sheath.  3.  A  sin- 
gle layer  of  flat  cells  lying  next  to  the  outer  layer  of 
the  internal  root-sheath.  The  internal  root-sheath 
begins  below  at  the  neck  of  the  papilla,  and  passing 
upwards  ends  abruptly,  as  if  cut  off,  at  the  neck  of  the 
hair-follicle,  where  the  sebaceous  gland  empties  into  it. 
It  consists  of  three  layers,  according  to  most  anato- 
mists: 1.  An  external  or  Henle's  layer.  2.  A  middle 
or  Huxley's  layer.  3.  An  internal  or  cuticular  layer. 
The  external  or  Henle's  layer  is  composed  of  only  a 
single  row  of  flat  ceUs.  The  middle  or  Huxley's  layer 
is  usually  formed  of  a  single  row  of  short  cylindrical 
cells;  but  when  connected  with  the  thick  hairs  of  the 
beard  it  at  times  has  a  second  row  of  cells.  The  inter- 
nal or  cuticular  layer  is  similar  in  formation  to  that  of 
the  hair  cuticle,  being  composed  of  a  single  layer  of 
flat  cells  which  rest  one  above  the  other  hke  scales.  In 
the  upper  regions  of  the  hair- root  they  are  cornified. 
The  cuticle  of  the  sheath  differs  from  that  of  the  hair, 
in  its  cells  standing  oblique  to  the  long  axis  of  the  hair 
and  pointing  downwards;  while  those  of  the  hair  have 
their  long  diameter  parallel  with  it  and  point  upwards. 
There  thus  results  an  inteilocking  between  them,  and 
a  fast  union,  esx)ecially  in  the  middle  third  of  the  folli- 
cle, so  that  when  a  hair  is  plucked  from  the  skin  it 
usually  brings  with  it  a  part  of  the  internal  root  sheath. 
The  internal  root -sheath  can  readily  be  divided  into 
two  divisions,  a  lower  and  an  upper.  The  lower  one 
corresponds  to  the  region  of  the  papiUa.     All  its  cells 


ANATOMY  OF  THE  HAIR. 


29 


are  nucleated.  In  the  upper  region  the  cells  of  the 
cuticle  are  cornified,  and  those  of  the  Henle  layer  have 
lost  their  nuclei.  The  cells  of  Huxley's  layer  preserve 
their  nuclei  longer,  but  they  become  shrunken,  and 
finally  disappear.  Unna  (82  a)  proposes  to  do  away 
with  the  terms  Henle's  and  Huxley's  layer,  as  he  re- 
gards them  as  artificially  prepared  layers,  and  to  speak 
of  the  whole  as  the 
root-she  a  t  h .  As 
noted  already  he 
has  dropped  the 
term  *^  outer  root- 
sheath,"  regarding 
it  simply  as  a  part 
of  the  hair-follicle. 

The  Papilla.— 
The  hair-papilla  is 
situated  at  the  bot- 
tom of  the  hair-fol- 
licle in  connection 
with  its  circular 
fibrous  layer.  It  is 
a  wart  or  nipple- 
shaped  connective- 
tissue  projection, 
which  penetrates 
the  hair  bulb  from 
below.  It  has  a 
narrow  neck,  a 
strongly  developed,  wide  middle  pai't  or  body,  and  a 
fine  point.  Upon  it  the  hair  rests  ;  and  it  contains 
the. blood' vessels  for  the  chief  supply  of  its  nutriment. 

Twin  Hairs. — Giovannini  {Siy  ap.)  has  described  a 
curious  anomaly  of  hair-growth,  where  two  hairs  grow 
inside  of  a  single  follicle,  surrounded  by  a  common  in- 
ternal root-sheath.    At  the  bottom  of  the  f  olhcle  there 


Twin  Hair  after  Giovannini. 


30  DISEASES  OF  THE  HAIR  AND  SCALP 

were  two  separate  papillae,  one  for  each  hair.  At 
their  bases  by  transverse  section  they  were  of  irregular 
shape,  with  their  greater  diameter  in  the  same  direc- 
tion. The  hairs  were  of  a  more  or  less  regular  oval 
form.  Above  the  root  they  were  somewhat  kidney- 
shaped,  and  only  occasionally  oval  or  round.  In  the 
region  of  the  matrix  the  hairs  were  about  parallel ;  at 
the  neck  of  the  follicle  they  were  divergent ;  in  the 
shaft  they  were  sometimes  divergent,  sometimes  par- 
allel. In  the  neighborhood  of  the  follicle-ground  the 
matrices  of  the  hair  were  entirely  separated.  About 
the  middle  of  the  neck  they  were  joined,  to  become 
separated  and  again  joined  higher  up.  The  juncture 
was  made  sometimes  by  a  melting  together  of  the 
cuticle,  sometimes  by  a  bridge  formed  partly  of  cuti- 
cle, partly  of  cortex.  Sometimes  they  were  joined 
at  the  front,  sometimes  at  the  side. 

Blood-\t:ssels. — The  blood  supply  of  the  hair  is  de- 
rived  from  arterial  branches  which  surround  the  hair 
folhcles  in  the  form  of  a  capillary  net-work  between 
their  middle  and  external  layers  ;  and  from  small  arte- 
ries which  penetrate  the  papilla  from  below.  These  ar- 
terial branches  are  derived  from  the  sub-papillary  arte- 
rial anastomosis  of  the  skin.  According  to  Unna  (82  a) 
the  arteries  of  the  follicles  alone  are  derived  from  this 
source  and  enter  the  f  oUicle  in  its  middle  region,  while 
the  arteries  of  the  papillae  spring  from  the  deeper  cir- 
culation of  the  cutis.  The  veins  follow  the  same  di- 
rection. 

Nerves  and  Lymphatics. — Nerves  have  been  traced 
to  the  hair-folhcles,  but  not  to  the  hair-papillse  in  the 
human  subject.  Some  histologists  have  followed  them 
to  the  vitreous  membrane  of  the  foUicle;  and  Unna' 
(82  a)  has  demonstrated  that  the  prickle-cell  layer  of 
the  external  root- sheath  is  supplied  with  sensitive 
nerves.     He  describes  tlie  nerve  trunks  as  entering  the 


ANATOMY  OF  THE  HAIR.  31 

follicles  immediately  beneath  the  sebaceous  glands,  los- 
ing their  medulla  when  they  reach  the  vitreous  mem- 
brane through  which  they  pass,  and  then  breaking 
up  into  branches,  which  end  within  the  cells  with 
double-ended  extremities.  No  lymphatics  have  yet 
been  demonstrated  in  connection  with  the  hair. 

Arrectores  Pilorum. — The  muscles  of  the  hair  are 
comjiosed  of  smooth  muscialar  fibres  and  are  named  '  'ar- 
rectores pilorum/'  They  arise  from  the  lower  part  of  the 
papillary  layer,  pass  downwards  beneath  the  sebaceous 
glands,  and  are  attached  with  many  ends  to  the  middle 
part  of  many  iieighboring  hair-follicles  upon  the  side 
which  makes  an  acute  angle  with  the  skin. 

Sebaceous  Glands. — The  sebaceous  glands  are  of 
the  racemose  variety,  and  are  found  in  close  connection 
with  the  hairs  of  the  body,  from  two  to  six  glands 
emptying  into  each  hair-foUicle  in  its  upper  third.  In 
structure  they  consist  of  a  number  of  acini  which 
empty  by  a  common  duct.  They  are  composed  of  a 
delicate,  structureless  capsule,  the  memhrana  propria, 
which  continues  into  the  duct,  and  then  merges  into 
the  vitreous  membrane  of  the  hair-foUicle;  and  of  hn- 
ing  cells,  which  are  large,  though  short,  cubical  or  cy- 
lindrical epithelial  cells,  arranged  in  one  or  two  layers. 
These  pass  through  the  duct,  and  are  continuous  with 
the  cylindrical  cells  of  the  outer  root-sheath  and  of  the 
skin.  The  interior  of  the  gland  is  filled  with  the  fatty 
secretion.  The  size  of  the  glands  varies  in  different 
regions,  the  largest  of  those  connected  with  the  hair, 
being  on  the  nose,  measure  2  mm.  in  diameter  in  some 
places,  and  may  have  as  many  as  twenty  acini.  Some 
glands  are  but  ^^  of  an  inch  in  diameter.  Their  length 
varies  in  different  regions,  the  longest  being  on  the 
nose.  As  these  glands  are  offshoots  of  the  hair-folli- 
cles, the  external  layer  of  the  hair-follicles  passes 
around  them  and  supports  their  membrana  propria. 


CHAPTEE   11. 

PHYSIOLOGY. 

We  have  now  to  consider  the  phenomena  of  the  de- 
velopment, degeneration,  fall  and  regeneration  of  the 
hair;  its  pecuharities  of  form  and  constitution;  and  tht 
pai-t  it  plays  in  the  Hfe  history  of  the  human  being 
whom  it  clothes. 

Development. — Fcetal  Hair. — The  germs  of  the 
future  hair  appear  first  upon  the  face  (forehead)  and 
eyebi'ows  in  the  tenth  to  the  twelfth  week  of  foetal  life; 
on  the  Hps  in  the  fomteenth  week;  on  the  r^st  of  the 
head  in  the  sixteenth  week;  soon  after  upon  the  tiiink; 
a  few  weeks  later  upon  the  arms  and  legs;  and  at  last, 
in  the  seventh  month,  upon  the  backs  of  the  hands  and 
feet.  The  hair  itself  forms  about  one  month  later  and 
follows  the  same  order,  first  coming  on  the  eyebrows, 
and  so  on.  These  germs  of  the  future  hair  are  short 
peg-Hke  elevations  of  the  outer  embryonal  skin. 
Reissner  and  Gotte  considered  them  sweUings  of  the 
'".orium;  but  Waldeyer  (83)  and  Unna  (82  a)  are  in 
accoi-d  in  teaching  that  only  the  stratum  Malpighii  of 
the  epidermis  takes  part  in  their  formation,  the  corne- 
ous layer  passing  smoothly  over  them.  These  germ?- 
are  at  first  separated  only  by  a  fine  seam  of  connective 
tissue.  An  increase  and  heaping  up  of  round  and  spin- 
dle-shaped cells  then  slowly  takes  place  in  the  cutis 
connective-tissue  at  the  fundus  of  the  germs.  At  first 
these  cells  surround  each  germ  like  a  basket;  but  soon 
a  prominence  forms  by  tlie  cells  crowding  together  at 
one  part,  and  this  indents  the  bottom  of  the  hair  germ. 


PHYSIOLOGY.  3^ 

Thus  are  formed  the  primitive  hair-f oUicle  and  the  prim- 
itive hair-papilla.  According  to  Waldeyer  (83),  while 
these  changes  are  taking  place  in  the  connective  tis- 
sue, the  hair-germ  sends  a  sHghtly  knob-shaped  pro- 
jection down  into  the  underlying  cutis,  and  the  original 
elevation  disappears  The  outer  cells  of  the  hair-germ 
now  become  cylindrical,  place  themselves  crosswise, 
and  appear  as  a  continuation  of  the  basal  cells  of  the 
stratum  Malpighii  of  the  skin,  while  those  in  the  long 
axis  of  the  hair-germ  place  themselves  vertically,  grow 
longer  and  appear,  if  the  papilla  has  already  pene- 
trated from  below,  as  a  delicate  cone-shaped  body  rest- 
ing on  the  top  of  the  papilla.  This  is  the  primitive 
hair-cone  (Haarkegel)  of  Unna  (82  a). 

The  cornification  of  the  cells  of  the  primitive  hair- 
cone  begins  at  its  point,  and  proceeds  rapidly  down- 
wards on  its  external  layer  till  to  the  point  of  the  hair 
papilla.  The  lower  end  of  the  hair-cone  embraces  the 
papilla  more  and  more  as  the  upper  end  grows  nearer 
to  the  outer  surface  of  the  skin.  Where  the  hairs 
stand  almost  perpendicularly  to  the  skin,  the  grow- 
ing hair-cone  drives  the  corneous  layer  of  the  skin  be- 
fore it,  forming  a  rounded  elevation.  This  at  last 
gives  way,  and  the  point  of  the  hair  protrudes.  Where 
tlie  hair  is  placed  more  at  an  angle  to  the  skin,  it  some- 
times runs  for  some  distance  under  the  epidermis  in  a 
spiral  manner  before  piercing  it.  The  middle  part  of 
the  hair-cone  grows  more  rapidly  than  tlie  outer  part, 
and  soon  breaks  through  the  protecting  cell  layer  of 
the  primitive  hair-cone  as  a  formed  hair,  though  only 
consisting  of  cortical  substance.  The  outer  layer  of 
cells  becomes  the  inner  root -sheath  and  crumbles  grad- 
ually away  to  end  at  the  mouth  of  the  sebaceous  gland. 
The  remaining  cells  of  the  liair-germ,  which  are  still 
to  the  outside  of  the  external  layer  of  the  primitive 
hair-cone,  become  the  outer  root- sheath,  which  is  con- 


34  DISEASES  OF  THE   HAIR  AND   SCALP. 

tinuous  above  with  the  prickle -cell  layer  of  the  skin, 
and  ends  below  in  a  point  in  the  neighborhood  of  the 
papilla.  This  is  the  formation  of  the  primary  or  foetal 
hairs.  The  vibrissae,  and  the  hairs  of  the  eyehds,  outer 
nose  and  lips,  are  placed  almost  perpendicularly  to  the 
surface  of  the  skin.  In  other  situations  the  hairs  stand 
at  an  oblique  angle  to  the  surface  of  the  skin,  the  ob- 
hquity  increasing  with  the  size  of  the  hair,  so  as  to  afford 
more  space  for  the  lodgement  of  the  hair-f olhcle.  The 
more  obhquely  the  hairs  stand,  the  more  plainly  do  the 
arrectores  pili  muscles  appear,  servmg  to  bridge  over 
the  obtuse  angle  which  the  hairs  form  with  the  sur- 
face, and  to  sustain  them  in  position.  Where  the  hairs 
are  perpendicular  to  the  skin  these  muscles  do  not  ex- 
ist. The  body  of  the  foetus  at  the  seventh  month  is 
almost  entirely  covered  with  hair,  and  sometimes  this 
condition  persists  till  birth. 

Embryoxal  Hair  Change. — It  is  no  unusual  thing  to 
see  a  child  born  with  long,  colored  hair  upon  the  head, 
and  long,  light,  or  colorless  hair  upon  the  rest  of  the 
body  as  well  as  on  the  face.  Normally,  however,  in  the 
sixth  month  of  foetal  life,  or  at  the  beginning  of  the 
seventh,  the  embryonal  hair  change  takes  place,  com- 
mencing on  the  lip.  The  primitive  hair  is  raised  from 
the  papiUa,  and  its  root  end  becomes  knob-shaped  in- 
stead of  cap-shaped.  It  mounts  up  in  the  follicle  till  it 
reaches  its  middle  third,  where  it  remains  for  a  time, 
and  continues  growing,  gaining  its  nourishment  from 
the  epithelial  cells  of  the  part.  For  a  time  the  lower 
part  of  the  f olhcle  remains  open,  but  slowly  its  epithe- 
lial lining  disappears,  it  shortens,  and  the  papilla  atro- 
phies and  vanishes.  Now  a  new  epithelial  process  is 
sent  out  from  the  lower  part  of  the  old  hair,  passes 
downwards,  enters  the  lower  part  of  the  follicle,  mak- 
ing it  pervious  again,  and  becomes  indented  from  below 
by  a  new  papilla.     Then  there  is  a  new  growth  of  hair^ 


PHYSIOLOGY.       .  35 

upon  the  same  principle  as  in  the  embryonal  hair. 
This  process  takes  place  at  about  the  eighth  month, 
and  is  coincident  with  the  fall  of  the  primary  hair. 
The  fall  of  the  old  hair,  and  the  growth  of  the  new,  fol- 
lows in  the  same  order  as  in  the  first  appearance  of  the 
hair.  Even  if  the  child  is  born  with  a  good  deal  of 
hair  it  falls  soon,  showing  that  the  prim  ary  hairs  were 
already  loosened  from  their  papillae.  This  change  from 
embryonal  to  permanent  hair  is  a  change  in  type,  for 
the  new  hair  is  soon  furnished  with  a  medulla.  After 
this  there  is  no  change  in  type,  excepting  in  the  devel- 
opment of  new  hair  at  puberty,  though  the  old  hairs 
constantly  fall  out  and  are  replaced  by  new  hairs.^ 
As  the  child  grows  older,  its  head,  which  at  birth  is 
usually  sparsely  supplied  with  fine  hairs,  becomes  well 
covered  with  long,  colored,  dark  hairs,  and  its  eyebrows 
and  eyelashes  become  more  pronounced. 

Change  of  Hair  at  Puberty.— At  puberty  an- 
other change  in  the  hair  growth  takes  place,  consist- 
ing in  the  appearance  of  hair  upon  the  pubes  and  in 
the  axillae  of  both  sexes,  and  about  the  anus  and  on 
the  face  of  males.  Still  later  strong  hairs  grow  in  the 
nostrils  and  in  the  ears,  though  this  growth  may  be 
long  deferred.  It  is  notable  that  there  are  usually  no 
hairs  about  the  anus  of  a  woman.  In  women,  also,  the 
axiUary  hairs  are  generally  less  developed  than  in  men, 
and  often  they  are  entirely  wanting.  By  some  ob- 
servers, indeed,  it  is  stated  that  the  absence  of  axillary 
hairs  in  women  is  the  rule.  As  far  as  my  observation 
extends  they  have  almost  always  been  present. 

Varieties  of  Hair  Growth. — In  fuUy  developed 
adults  most  of  the  body,  excepting  in  the  regions  just 
mentioned,  is  supphed  only  with  colorless,  fine  lanugo 
hairs,  but  in  most  men  and  in  a  few  women  a  more  or 
less  luxuriant  growth  of  hair  will  be  found  upon  the 
chest  and  extremities.     In  the  male  the  pubic  hair  is 


o(3  DISEASES   OF   THE    HAIR   AND   SCALP. 

often  continuous  al)ove  with  a  pyramidal  growth  of 
hair  upon  the  middle  Une  of  the  abdomen.  In  women 
this  is  never  the  case,  the  pubic  hair  ending  by  a 
sharp  horizontal  line.  Hair  is  always  absent  from  the 
glans  penis  and  the  prepuce;  from  the  vermilion  bor- 
der of  the  hps:  from  the  labia  minora;  from  the  last 
plialanges  of  the  fingers  and  toes;  and  from  the  palms 
and  soles.  The  hair  of  women  grows  to  a  greater 
lengih  than  does  that  of  men,  even  if  the  latter  is  un- 
cut. The  hair  of  the  scalp  grows  in  groups,  two  or 
three  hairs  in  each  gToup,  seldom  as  many  as  four. 
The  hairs  of  each  gi^oup  are,  according  to  Pincus  (71), 
not  all  of  the  same  lengih,  because  they  are  not  all  of 
the  same  age. 

Hair  Centres. — The  hairs  are  not  only  placed  at  an 
angle  to  the  skin,  but  they  grow  from  a  number  of 
well-defined  centres.  Wilson  (S4)  has  studied  these 
and  carefully  described  them  as  follows:  "  The  hairs 
of  the  head  radiate  from  the  croT\Ti  with  a  gentle 
sweep  l:)ehind  towards  the  left  and  in  front  towards 
the  right.  The  centre  for  the  forehead  is  a  median 
vertical  line  from  wliich  the  hair  passes  to  the  right 
and  left,  the  loAver  border  of  the  growth  forming  the 
upper  half  of  the  eyebrows.  This  centre  is  distinctly 
visible  in  its  whole  length  in  many  newborn  children. 
At  the  inner  angle  of  each  eye  is  another  centre  from 
which  the  hair  radiates,  the  upper  and  inner  rays  as- 
cending to  the  hue  between  the  eyebrows,  where  tliey 
often  meet  those  from  the  opposite  side  and  form  with 
them  a  line  across  the  root  of  the  nose;  and  the  upper 
and  outer  rays  curve  along  the  brow  and  form  the 
lower  half  of  tlie  eyebrow.  The  lower  and  outer  rays 
^Wth  those  of  the  nose,  mouth  and  chin  make  a  sweep 
over  the  cheek  and  side  of  the  face.  On  the  upper  lip 
the  hair  gi'ows  from  the  nostrils  outwards,  and  forms 
the  mustache;  on  the  lower  Hp  there  is  a  middle  line 


PHYSIOLOGY.  37 

for  a  centre.  The  beard  is  formed  by  the  convergence 
of  two  side  currents  which  meet  at  the  middle  Hne. 
On  the  trmik  there  is  a  centre  of  radiation  from  each 
armpit  and  two  lines  of  divergence,  one  of  the  latter 
proceeding  from  this  point  horizontally  to  the  middle 
of  the  front  of  the  chest,  the  other  vertically  alone;- 
the  side  of  the  trunk,  across  the  front  of  the  hip,  and 
down  the  inside  of  the  thigh  to  the  bend  of  the  knee. 
From  the  armpit  centre,  and  from  the  upper  side  of 
the  hoi'izontal  line,  a  broad  and  curved  current  sweeps 
upward  over  the  upper  part  of  the  front  of  the  chest 
and  around  the  neck  to  the  back.  From  the  lower  side 
of  the  horizontal  line  and  from  the  vertical  hne  the  set 
of  the  current  is  downwards  and  inwards,  with  a  gen- 
tle undulation  to  the  middle  hne  in  front,  and  back- 
wards to  the  spine. 

''  From  the  armpit  centre  there  proceeds  another  line 
of  divergence  which  encircles  the  arm  like  a  bracelet 
immediately  below  the  shoulder.  From  the  upper 
margin  of  this  hne  the  direction  of  the  current  is  up- 
wards over  the  shoulder,  and  then  backwards  to  the 
mid-line  of  the  body.  Another  line  commences  at  this 
ring  on  the  front  of  the  arm,  and  runs  in  a  pretty 
straight  course  to  the  cleft  between  the  index  finger 
and  thumb  on  the  back  of  the  hand.  This  is  the  line 
of  divergence  of  the  arm.  From  it  and  from  the  ring, 
the  stream  sets  at  first  with  a  curve  forwards,  and  then 
with  a  curve  backwards  to  the  point  of  the  elbow.  In 
the  forearm  the  currents  sweep  downwards  in  front, 
and  upwards  behind  towards  the  point  of  the  elbow, 
which  is  thus  the  centre  of  convergence.  On  the  back 
of  the  hand  and  fingers  there  is  an  outward  sweep  with 
the  concavity  upwards.  On  the  lower  hmb  there  are 
two  vertical  lines  of  divergence,  the  one  being  the  con- 
tinuation of  that  of  the  side  of  the  trunk,  proceeding 
around  the  inner  side  of  the  thigh  to  the  bend  of  the 


38 


DISEASES  OF  THE  HAIR  AND  SCALP. 


knee  ;  the  other,  an  undulating  hue,  beginning  at  about 
the  middle  of  the  hip,  and  running  down  the  outer  side 
of  the  thigh  and  leg,  and  across  the  instep  to  the  cleft 
between  the  great  and  second  toes.  A  short  oblique 
line  connects  the  two  vertical  lines  at  the  bend  of  the 
knee  On  the  front  of  the  thigh  the  streams  from 
the  two  lines  converge  and  descend  towards  the  knee. 
On  the  back  they  converge  also  at  the  middle  hue,  but 
ascend  toward  the  trunk  of  the  body  On  the  leg, 
where  there  is  but  one  line,  the  diverging  currents 
sweep  round  the  limb,  and  meet  upon  the  shin,  while 
on  the  foot  they  diverge  with  a  sweep,  as  upon  the 
back  of  the  hand.     The  hair  centres  are  called  whorls. 

Shedding  of  Hair.— At  certain 
times  of  the  year  animals  ' '  shed 
their  coat, ''  that  is,  a  rapid  fall  of 
hair  takes  place  and  the  animal's 
coat  is  thinned.  At  the  same 
time  with  the  fall  of  the  old  hair 
there  is  a  growth  of  new  hair  and 
soon  the  coat  is  as  thick  as  ever. 
In  the  human  species  there  is, 
instead  of  a  periodic  shedding,  a 
constant  fall  and  new  gro^^i^h  of 
hair,  though  at  certain  seasons  it 
may  proceed  more  rapidly  than 
at  other  seasons.  This  is  accom- 
plished in  the  same  way  as  we 
learned  when  describing  the  em- 
bryonal hair  change,  namely:  the 
hair  loosens  from  its  papilla  and 
mounts  up  to  the  middle  foUicle 
region,  where  it  remains  for  a 
time  attached  to  the  prickle-cell 
lajev  of  the  foUicle,  and  grows 
The  lower  part  of  the  follicle  collapses,  and  the 


Section  of  hair  follicle  show- 
ing beprinning  separation  of 
hair  from  papilla  ^.Unna.) 

there. 


PHYSIOLOGY.  39 

papilla  grows  smaller.  The  lower  end  of  the  old  hair 
becomes  broom-like  and  knob  -shaped.  This  appearance 
is  due  to  new  cornified  cells  being  constantly  attached 
to  the  root  as  it  mounts  up  in  the  folhcle. 

Bed-hair. — The  hair  in  this  position  is  called  by 
Unna  (82  a)  a  ^'  bed-hair  "  (Beethaar),  to  distinguish  it 
from  the  hair  seated  upon  its  papilla,  or  ^'papillary 
hair.^^  The  part  of  the  follicle  from  which  it  grows, 
he  names  the  ''Haarbeet,"  or  ''hair-bed."  The  ''bed- 
hair  "  is  always  secondary  to  a  papillary  haii-,  and  all 
hairs  go  through  this  stage  before  they  fall  They  are 
distinguished  from  papillary  hairs  by  absence  of  root- 
sheath,  want  of  cuticle  and  medulla  in  their  roots,  and 
by  having  their  pigment  distributed  in  stripes  and  heaps. 

The  cause  of  the  loosening  and  shedding  of  hair, 
whether  at  the  close  of  its  normal  length  of  life,  or  on. 
account  of  some  disease,  as  eczema,  typhus  fever  and  the 
like,  is  to  be  sought  for,  according  to  Unna  (82  a),  in  the 
character  of  the  blood  supply  of  the  hair.  As  we  have 
learned,  the  middle  region  of  the  hair  f  oUicle  is  supphed 
by  arterial  twigs  from  the  sub-papillary  circulation, 
and  the  papilla  of  the  hair  is  nourished  from  little  ar- 
teries from  the  deeper  arterial  circulation  of  the  cutis. 
Therefore  the  middle  follicle  region  must  participate  in 
the  disturbances  of  the  sub-papillary  circulation,  while 
the  papilla  is  relatively  free  from  this  influence.  Thus 
any  lessening  of  the  nutritive  supply  to  the  papilla,  or 
any  increase  in  that  from  the  sub-papillary  circidation 
to  the  middle  follicle  region  must  cause  a  preponder- 
ance of  nutrition  in  the  middle  over  the  lower  follicle 
region.  This  would  necessarily  cause  an  increased 
growth  of  the  prickle-cell  layer  of  the  middle  follicle 
region,  and  an  increased  pressure  upon  the  hair.  Then 
either  the  circumference  of  the  hair  cylinder  would  be 
lessened,  or  the  hair  itself  w^ould  be  pressed  out  of  the 
f oUicle  and  raised  from  the  papilla.     The  latter  is  what 


40 


DISEASES  OF  THE   HAIR  AND   SCALP. 


actually  takes  i)lace.  The  bed-hair  is  shoved  higher 
and  higher  up,  so  long  as  it  remains  in  the  middle  third 
of  the  follicle,  but  when  it  reaches  the  unproductive 
part  of  the  foUicle,  that  is,  just  below  the  mouth  of  the 
sebaceous  gland,  the  circulation  becomes  again  equal- 
ized, and  the  hair  ceasing  to  grow,  falls  out.  The  final 
fall  of  the  hair  is  hastened  both  by  the  pressure  of  the 
new  hair  from  below,  and  by  traction  exerted  upon  it 
from  above  by  brushing,  combing,  and  the  like.  The 
loosening  of  the  hair  from  its  papilla 
begins  at  the  cuticle,  and  proceeds 
from  without  inwards. 

According  to  Giovannini  (87  ap.), 
when  a  coarse  hair  is  plucked  from 
its  follicle,  the  latter  shrinks  up  and 
its    cavity    completely    disappears. 
-M       The  papilla  diminishes    slightly    in 
illi--M  ^^olume,  and  approaches  to  the  lower 
edge  of  the  derma,  while  from  below 
it  gives  off  a  connective-tissue  pel- 
^-■^  hcle  containing  blood-vessels.    In  the 
intra-dcrmic  portion  of  the  follicle 
the  shrinkage  goes  on  more  i-apidly 
in  the  upper  and  lower  than  in  the 
middle  portion  of  the  follicle.     The 
widest  portion  is  where  the  arrectores 
pilorum    muscles    are   attached.     A 
new  hair  begins  to  form  in   from 
forty-one  to  seventy-two  days  after 
Section  of  hair  follicle  epilation,  aud  is  fully  formed  in  from 

skow mg   liair  in      beet-     ^  ^  '    ^  -^ 

haar  ^' stage,  and  growth  thirty  to  sixty  days  afterwards. 
tr^trUZ;,^     Regeneration   of   HAiR.-While 
hb  =  hair   bed,   from  the  bed-liair  IS  still  in  the  middle 

.hieh6/.grows(Unna.)    ^^^-^j^   ^.^^.j^^^   ^j^^    fomiatioU   of    the 

new  hair  is  under  way.     From  the  lower  end  of  the 
old  hair  down  to  the  papilla  there  stretches  an  ei^ithe- 


PHYSIOLOGY.  41 

lial  process  composed  of  the  old,  collapsed,  and  greatly- 
atrophied  root-sheath.  This  enlarges,  its  cells  increase, 
it  grows  downwards  into  the  old  hair  follicle,  wiiich 
again  becomes  open,  and  shoves  the  old  papilla  before 
it.  Out  of  this  a  new  hair  is  formed,  seated  upon  the 
old  papilla  which  takes  on  new  activity.  The  whole 
process  is  analogous  to  that  which  occurs  in  the  foetus. 
The  new  hair  mounts  up  in  the  old  follicle  and  grows 
sometimes  alongside  the  bed-hair,  but  more  often  it 
pushes  it  out  ahead  of  it.  This  new  hair  lives  its  ap- 
pointed time  and  then  undergoes  the  same  fate  as  its 
predecessor,  and  thus  is  constantly  repeated  the  regu- 
lar normal  fall  and  regeneration  of  the  hair.  It  is 
possible  that  new  papillae  may  be  formed,  producing 
new  hairs,  but  the  above  is  the  usual  course . 

Appearances  of  Hair. — The  microscopical  appear- 
ances of  the  hair  will  vary  according  to  whether  it  is  a 
lanugo  hair,  bed-hair,  or  papillary  hair ;  or  whether 
it  has  been  plucked  from  the  head,  or  has  fallen  of 
itself.  The  lanugo  hairs  are  very  fine  and  downy, 
colorless  or  very  slightly  colored,  and  contain  no  me- 
dulla. Their  roots  are  small.  The  bed-hair  has 
neither  root-sheath,  cuticle  nor  medulla  in  its  root,  and 
the  root  itself,  instead  of  being  hollow,  is  rounded  off 
and  shaped  somewhat  like  an  old-fashioned  broom  of 
twigs,  or,  it  may  be  likened  to  a  fir  tree  in  shape,  as 
Unna  suggests.  Sometimes  the  medulla  is  entirely 
absent  throughout  its  length.  These  appearances  are 
those  commonly  seen  in  fallen  hairs.  This  we  should 
expect  from  what  we  have  already  learned  of  their  na- 
ture. The  papillary  hair  has  a  long,  pliable,  soft  root- 
end,  which  is  bulb-shaped  and  hollowed  out  for  the  re 
ception  of  the  papilla.  All  the  component  parts  of  the 
hair  are  present  in  it,  and  the  medulla  can  be  followed 
from  its  root  to  near  its  point.  When  such  a  hair  is 
phicked,  it  presents  for  observation  in  addition  to  the 


42  DISEASES   OF   THE   HAIR  AND   SCALP. 

above,  an  attached  piece  of  the  root-sheath  which 
makes  its  lower  paii  look  swollen.  These  are  the  typ- 
ical forms  of  hair.  If  the  microscoj^e  is  focused  upon 
the  surface  of  a  hair,  the  edges  of  the  cuticle  cells  will 
be  seen  as  dark  lines  like  the  edges  of  the  slates  in  a 
slate  roof.  If  it  is  focused  carefully  upon  the  edge  of 
the  hair,  the  latter  \\dll  look  hke  the  edge  of  a  fine  saw 
blade,  as  the  edges  of  the  cuticle  cells  overlap  one  an- 
other. If  now  the  tube  of  the  microscope  be  lowered, 
the  cortical  substance  wiU  come  into  view.  It  ap- 
pears like  a  solid  body  marked  by  short  stripes  of  a 
darker  color,  which  gives  it  the  appearance  of  being 
composed  of  fibres.  The  fibres  are  in  reahty  long 
spindle- formed  cells,  as  is  learned  by  tracing  the  hair 
toward  the  root,  when  their  ceU  form  \vi]l  be  more 
apparent.  Fine  black  granules  are  scattered  about  or 
gathered  in  heaps  in  its  substance.  These  are  the 
pigment  granules.  Lastly  Ave  meet  with  long,  oval, 
irregularly  shaped,  or  small,  round,  dark  bodies  lying 
between  the  fibres.  These  are  air -globules.  The  small 
ones  may  be  grouped  and  mistaken  for  pigment,  a  mis- 
take easily  rectified  by  altering  the  focus,  wiien  they 
wiU  present  the  changes  of  color  dependent  upon  their 
optical  properties,  becoming  lighter  as  we  raise  the  tube 
of  the  microscope.  The  medulla  runs  through  the 
centre  of  the  hair  as  a  dark  streak.  In  hmnan  hair, 
Avhen  examined  in  water  alone,  the  sepai'ate  ceUs  of 
which  the  medulla  is  composed,  are  not  \asible,  as  a 
rule.  This  is  owang  to  the  presence  of  a  large  amount 
of  pigment  and  air  between  the  ceUs,  both  of  which 
have  the  effect  of  rendering  the  medulla  dark  colored 
by  transmitted  light.  If  the  hair  be  laid  in  glycerine, 
the  au'-giobules  wiU  be  driven  out,  and  the  ceUs  wiU 
become  more  apparent.  The  form  of  the  medulla  ceUs 
has  been  given  in  the  chapter  on  the  anatomy  of  the 
hair. 


PHYSIOLOGY.  43 

Technique. — A  word  must  be  said  as  to  the  proper 
methods  of  examining  hair.  For  most  examinations  of 
the  hair,  an  ordinary  microscope,  magnifying,  say,  250 
diameters,  is  sufficient.  If  you  have  higher  powers  so 
much  the  better  The  hair  should  be  examined  at  first 
under  a  covering  glass  alone.  Then  water  should  be 
added  and  the  hair  again  examined.  To  render  the 
hair  transparent,  it  should  be  placed  in  liquor  potassae 
alone,  or  in  liquor  potassae  and  glycerine.  The  per- 
oxide of  hydrogen  acts  even  better  than  liquor  potassae 
as  a  bleaching  agent,  as  it  bleaches  the  pigment  and 
does  not  destroy  the  hair.  Unfortunately  it  soon  loses 
its  virtues  by  keeping.  Waldeyer  (83)  recommends 
a  twenty  per  cent,  solution  of  nitric  acid  for  rendering 
the  hair  transparent.  If  there  be  much  foreign  mat- 
ter adherent  to  the  hair,  place  the  latter  in  a  small  test 
tube  containing  ether  and  shake  it  for  some  time,  or 
put  it  in  a  corked  bottle  with  ether  and  let  it  stand. 
These  methods  are  sufficient  for  the  proper  examination 
of  both  healthy  and  diseased  hair. 

Color. — The  color  of  the  hair  depends  upon  four  fac- 
tors, namely:  1.  Diffused  pigment.  2.  Granular  pig- 
ment. 3.  Air  contents;  and  I.  The  superficial  charac- 
ter of  the  hair.  The  cortex  plays  the  chief  part  in  de- 
termining the  color  of  the  hair.  1.  The  diffused 
pigment  or  essential  color  of  the  hair  gives  it  a  light - 
brv3wn  to  a  dark-red  hue,  according  to  its  intensity. 
2.  The  granular  pigment  lies  in,  (Waldeyer,  83)  or 
between  (Unna,  82  a)  the  cells  or  fibres  of  the  cortex, 
and,  in  some  cases,  in  the  cells  of  the  medulla.  It  is 
found  chiefly  in  the  peripheral  portion  of  the  cortex, 
and  occurs  either  scattered  or  grouped.  Sometimes  it 
is  heaped  up  so  thickly  that  the  individual  granules  are 
indistinguishable.  Its  color  is  a  shade  of  brown,  any- 
where from  a  light  -brown  to  ebony.  The  combinations 
of  the  diffused  and  granular  pigment  makes  the  vari- 


44  DISEASES   OF   THE    HAIR   AM)   SCALP. 

ous  shades  of  color  met  ^\ith.  The  darker  the  hair  is  the 
more  granular  pigment  it  contains,  but  even  the  hghtest 
of  blonde  hair  will  be  found  to  contain  some  granular 
pigment.  3.  The  air-globules  are  generally  in  the  outer 
layers  of  the  cortex.  Viewed  by  direct  hght  they  ap- 
pear under  the  microscope  as  briUiant  points;  by  trans- 
mitted hght  they  appear  black.  4.  By  the  supei-ficial 
character  of  the  hair  is  meant  whether  it  is  smooth  or 
rough.  These  two  last  factors  influence  the  color  of 
the  hair  on  account  of  a  law  in  optics,  namely:  Every 
body  appears  white  in  wliite  daylight  if  it  reflects  the 
white  light  to  all  sides.  If  the  surface  of  the  hair  be 
uneven,  and  there  are  many  httle  particles  of  air  in  the 
cortex  and  medulla,  the  hght  will  be  thus  reflected 
and  the  color  of  the  hair  will  be,  therefore,  more  or 
less  white,  the  tone  being  modified  by  the  amount  of 
pigment  present  in  the  cortex.  A  hair  containing  pig- 
ment never  appears  quite  white,  even  if  air  be  present, 
but  some  shade  of  gray.  If  there  be  no  air  present,  or 
the  pigment  is  m  excess,  the  hair  will  be  more  or  less 
purely  of  the  color  of  the  pigment.  The  most  univer- 
sal color  of  hair  is  dark  brown  or  black. 

Pigment. — The  somxe  of  the  pigment  is  not  yet  sat^ 
isfactorily  settled.  It  is  derived,  without  doubt,  from 
the  coloring  matter  of  the  blood,  as  is  all  the  pigment 
of  the  body.  Ehrmann  (100  and  101)  of  Viemia, 
pubhshed,  in  the  years  1SS4,  1>185  and  1SS6,  some  ex- 
ceedingly interesting  and  valuable  obsei^vations  upon 
the  formation  of  pigment  in  tlie  skin  and  hau\  His 
studies  were  made  in  the  beghming  upon  frogs  and 
salamander;  later  upon  the  skin  of  dogs  and  men. 
He  has  found  that  the  pigment  is  produced  only  in  the 
corium,  in  parts  innnediately  surrounding  the  blood- 
vessels, and  that  ceU  acti^^ty  is  absolutely  essential 
thereto.  From  the  corium  it  reaches  the  epidermis 
through  protoplasmic  movement.     The  pigment  ceUs 


PHYSIOLOGY.  45 

in  men  are  round  or  oval,  with  short  or  few  branches 
or  prolongations.  They  are  in  the  basal  cells  of  the 
epidermis  and  send  their  prolongations  downwards  into 
the  corium,  to  connect  with  the  pigment -carrying  cells 
of  that  part.  The  latter  are  not  a  pecuHar  species  of 
cells,  but  true  connective-  tissue  cells. 

But,  we  are  interested  now  more  especially  with  the 
l)igment  of  the  hair.  Pigment-carrying  cells  are  found 
in  the  hair  pajiilla,  which  are  large  in  its  neck  and 
lower  parts,  and  small  in  its  top.  As  yet  no  Ijranches 
have  been  observed  to  these  cells.  The  ])igment  cells 
proper  lie  for  the  most  part  in  the  bases  of  the  mat- 
rices, entirely  included  in  them,  and  touch  the  boundary 
of  the  papilla  only  with  one  side  of  their  circumfer- 
ence. Their  branches  pass  only  upwards  between  the 
cells  of  the  matrix  of  the  cortex  up  to  the  point  where 
these  begin  to  undergo  cornification.  The  cells  them- 
selves of  the  cortex  are  devoid  of  pigment.  Further 
up  in  the  hair  matrix,  the  branches  of  the  pigment 
cells  form  a  net-woi'k,  and  the  cortical  cells  of  the  third 
or  fourth  row  are  in  close  connection  with  this  net- 
work, and  themselves  contain  pigment. 

Life  Phenomena. — The  length  of  life  of  the  hair 
varies  with  the  age,  sex,  character  of  hair,  and  indivi- 
dual peculiarity.  Each  hair  has  its  determined  length 
of  life,  and  this  is  not  the  same  for  every  hair  of  the 
same  sort.  What  may  be  the  circumstances  that  de- 
termine the  period  of  its  existence  is  not  known.  The 
lifetime  of  the  eyelashes  has  been  determined  by 
Mahly  as  one  hundred  and  thirty  five  days.  PiNCUS 
(71)  says  that  the  period  of  hair  growth  on  the  human 
head  is  from  two  to  six  years.  Hair  is  said  to  grow 
faster  by  day  than  by  night,  and  in  the  warm  weather 
rather  than  in  the  cold.  Shaving  and  cutting  the  hair 
certainly  make  it  coarser,  and,  may  be,  stimulate  its 
growth.     The  average  length  of  the  hair  of  the  head 


40  DISEASES   OF   THE   HAIR   AND   SCALP. 

in  women  of  the  Anglo-Saxon  race  is  from  eighteen  to 
twenty-four  inches,  when  left  uncut.  Exceptionally 
it  may  grow  to  thirty-six  or  even  fifty  inches  or  more 
in  length.  The  hair  of  men  of  the  same  race  has  an 
average  length  of  six  to  eight  inches;  hut  custom  de- 
manding that  it  be  cut  from  time  to  time,  it  is  rarely 
seen  of  this  length.  The  hair  of  each  individual 
has  its  own  detei-minate  length,  and  the  hair  of  men, 
even  if  left  uncut,  will  not  grow  as  long  as  that  of 
women.  The  rate  of  growth,  specially  in  yoruig  women, 
is  from  2  to  5  mm.  during  each  ten  days  after  first 
piercing  the  skin.  When  it  reaches  a  length  of  ten  to 
fourteen  inches  its  rate  of  groTd^h  is  reduced  one  half; 
and  later  towards  the  end  of  its  normal  life  its  increase 
is  hardly  perceptible.  The  short,  stiff  hairs,  as  of  the 
eyebrows,  are  from  i  to  1  inch  long. 

Hairs,  ^^athout  their  papillae,  have  been  transplanted 
and  become  fixed  on  granulating  wound  surfaces  and 
on  the  iris.  I  do  not  know  that  they  have  actually 
taken  root  and  grown  there. 

The  average  number  of  hairs  to  the  square  inch 
is  given  by  Wilson  (SI)  as,  on  the  scalp,  l,OuO. 
WiTHOF  (83)  found  on  a  man  in  one  quarter  of  a 
square  inch  of  the  crown  of  the  head,  293  hairs; 
occiput,  225;  anterior  part  of  the  head,  211;  chin,  39; 
pubes,  34;  forearm,  23;  back  of  the  hand,  19;  anterior 
surface  of  the  thigh,  13.  Wilson  (84)  calculates  that 
there  are  120,000  hairs  upon  the  head  of  an  adult.  As 
a  rule  the  finer  the  hairs,  the  thicker  they  will  stand  on 
the  head. 

The  dJameter  of  the  hair  varies  \\Tith  its  color  and 
location,  and  with  the  age  and  sex  of  the  individual. 
Wilson  (84)  found  that  fiaxen  hair  was  the  finest,  and 
black  hair  the  coarsest;  that  the  hairs  of  the  beard 
and  whiskers  were  coarser  than  those  of  the  breast  and 
eyebrows, and  then  in  order  of  decreasing  diameter  came 


PHYSIOLOGY.  4 1 

those  of  the  eyelashes  and  armpit,  of  the  head,  of  the 
thigh,  and  of  the  leg,  the  latter  being  finest.  The  finest 
hairs  of  the  scalp  in  the  Anglo-Saxon  race  are  from 
TTFo  to  swo  in.,  while  the  coarsest  are  from  4^0  to  yio 
in.  in  diameter.  The  head  hair  of  a  woman  is  some- 
what coarser  than  that  of  a  man,  the  diameter  of  the 
former  being  from  ^Jo  to  2+0  hi. ;  that  of  the  lattei' 
from  yj-j  to  3^  in.  As  a  general  rule,  the  hair  of  chil 
dren  is  finer  than  that  of  adults,  ranging  from  -j|y  to 
4^0  in.  in  diameter.  Even  on  the  same  head  there  is  a 
great  diversity  in  the  diameter  of  different  hairs,  and 
individual  hairs  are  not  of  the  same  thickness  through- 
out. As  stated  in  the  first  chapter  (p.  21)  the  contour 
of  the  hair  is  circular,  oval  or  flattened.  Whether  a 
hair  is  to  be  curly  or  straight  is  largely  dependent  upon 
its  contour;  the  more  oval  or  flattened  it  is,  the  more  it 
will  be  curled.  The  curliness  is  influenced,  also,  by 
the  condition  of  the  atmosphei-e;  naturally  curled  hair 
becomes  more  curled  when  the  air  is  surcharged  with 
moisture,  and  less  so  in  dry  weather.  But  artificially 
curled  hair  always  loses  its  curi  in  damp  weather. 

Race  Differences. — Ethnographical  classifications 
have  been  founded  upon  the  evident  differences  exist- 
ing in  the  hair  of  different  races  of  men.  We  are  all 
familiar  with  differences  of  color,  as  between  the  black 
hair  of  the  Negro,  and  the  flaxen  hair  of  the  Saxon  race; 
and  of  form,  as  between  the  close  curled  hair  of  the 
Negro,  and  the  long  straight  hair  of  the  American  In- 
dian. As  marked  differences  between  races  exist  in 
the  contour  of  the  hair,  in  the  manner  of  its  grouping, 
etc.  But  a  discussion  of  these  matters  of  classification 
is  foreign  to  our  purpose,  and  we  will  content  ourselves 
with  the  mere  statement  of  the  fact. 

Physical  Peculiarities. — It  has  already  been  stated 
that  the  curliness  of  the  hair  is  influenced  by  the 
moisture  of  the  atmosphere.     This  is  because  the  hair 


4.^  DISEASES   OF  THE   HAIR  AND   SCALP. 

is  ]iYgiT)ScopiCj  absorbs  moisture  very  i^adily  from  the 
atmosphere,  and  becomes  lengthened,  as  well  as  more 
rounded.  Hair  is  also  elastic,  and  is  capable  of  being 
stretched  from  one-fifth  to  one-third  of  its  normal 
length.  When  the  tension  is  renioved  it  will  retract 
to«  nearly  but  not  quite  its  original  length.  It  possesses  a 
considerable  amount  of  strengih,  a  good  healthy  adult 
hair  being  capable  of  sustaining  a  weight  of  from  two 
to  four  ounces  without  breaking.  The  qualities  of  elas- 
ticity and  resistance  are  mainly  located  in  the  fibrous 
portion  or  cortex  of  the  hair.  Hair  is  strongly  electric 
hj  friction,  particularly  in  cold  and  dry  weather.  Its 
electricity  may  readily  be  shown  by  passing  a  rubber 
comb  through  the  long  hair  of  a  woman,  when  a  slight 
crackling  sound  will  be  heard  In  peculiarly  susceptible 
individuals  the  hairT\iU  stand  almost  straight  out  from 
the  head  under  this  electrical  stimulus.  The  electricity 
of  the  hair  is  negative. 

Chemical  Constitution.— The  chemical  constitu- 
tion of  the  hair,  as  given  by  Waldeyer  (83)  from  sev- 
eral  recent  analyses,  is  as  foUows:  One  hundred  parts 
of  dry  hair  contain  from  yV  to  -i\  part  of  incombustible 
material.  This  contains  28  per  cent,  of  alkaline  sul- 
phates, 2  to  10  per  cent,  oxide  of  iron,  and  -40  per  cent, 
silica.  Dark  hair  contains  somewhat  more  iron.  The 
analysis  of  the  hair  substance  shows  it  to  be  composed 
of  carbon,  50;  hydrogen,  6.30;  nitrogen,  17.14;  oxygen, 
20.85;  sulphur,  5.  The  hair  is  said  to  contain  a  cer- 
tain proportion  of  an  oily  substance,  the  color  of  which 
varies  with  that  of  the  hair.  The  proportions  of  the 
chemical  constituents  vary  with  the  color  of  the  hair. 
Thus,  fair  hair  contains  least  carbon  and  hydrogen  and 
most  oxygen  and  sulphur;  brown  hair  gives  the  lar- 
gest proportion  of  carbon  and  the  smallest  quantity  of 
oxygen  and  sulphur;  white  hair  of  the  aged  contains 
a  considerable  amount  of  bone  earth  or  phosphate  of 


PHYSIOLOGY.  49 

lime.  The  quantity  of  nitrogen  remains  the  same  in 
all. 

Uses  of  Hair. — The  uses  of  the  hair  are  fom^f old:  1. 
As  a  preservative  of  heat.  2  As  a  protective  agency. 
3.  As  an  organ  of  touch.  4.  As  a  promoter  of  beauty. 
(1.)  As  the  hair  is  a  bad  conductor  it  serves  to  preserve 
the  heat  of  the  body.  When  one  is  exposed  either  to  ex- 
cessive heat  or  cold  the  hair  is  apt  to  grow  more  luxuri- 
antly. (2.)  The  hair  of  the  head  forms  a  thick  elastic 
cushion,  and  is  thus  an  admirable  defence  to  the  skull 
against  blows  and  falls.  The  pubic  hair  in  like  manner 
acts  as  a  cushion  during  coitus.  The  eyebrows  are  a  de- 
fence to  the  eye  against  ])lows,and  turn  the  perspiration 
to  the  outside  of  the  eye-socket,  thus  preventing  its  gain- 
ing access  to  the  eye.  The  eyelashes  catch  flying  par- 
ticles of  dust;  the  hairs  of  the  nostrils  and  ears  prevent 
insects  from  crawling  into  the  cavities  which  they  pro- 
tect, as  well  as  guard  against  the  entrance  of  other  for- 
eign substances;  the  mustache  acts  as  a  respirator;  and 
the  beard  protects  the  larynx  from  the  action  of  cold. 
(3.)  Parts  furnished  with  hair  are  more  sensitive  than 
are  those  without  it.  This  is  because  the  hair,  being 
planted  at  an  angle  to  the  skin,  acts  as  a  lever  on  l)eing 
touched,  shoves  to  one  side  the  hair- follicle,  and  thus 
causes  a  slight  irritation  of  the  neighboring  cutaneous 
nerves.  This  sense  of  touch  in  man  is  but  little  develop- 
ed. (4.)  Of  the  hair  as  a  promoter  of  beauty,  little  need 
be  said,  as  it  will  be  conceded  by  all  that  the  hair  is 
an  adornment. 

Uses  of  the  Sebaceous  Glands.— The  sebaceous 
glands  furnish  an  oily  secretion  to  the  hair  which  ren- 
ders it  pliable  and  soft,  and  gives  it  lustre.  This  secre- 
tion is  a  constant  one  in  health,  and  is  the  result  of  a 
fatty  degeneration  of  the  lining  cells  of  the  glands, 
which  slowly  fill  up  with  the  oily  matter,  burst,  and 
discharge  their  contents.     As  the  sebaceous  glands 


50  mSEASES-  OF   THE  HAIR   AND   SCALP. 

empty  into  the  hair-follicles  in  their  upper  third,  they 
are  admirably  located  for  lubricating  the  hair  just  be- 
fore its  exit  into  the  outer  air.  The  oil  is  upon  the  out- 
side of  the  hair  and  also  within  it.  It  reaches  the  in- 
terior of  the  hair  b}'  capillary  attraction,  as  Avill  be 
readily  understood  by  referring  to  the  anatomy  of  the 
hair,  and  noting  its  fibrillar  construction  and  the  spaces 
between  its  fibres.  Pincus  believes  that  the  capillary 
attraction  is,  to  a  certain  extent,  assisted  by  the  pres- 
sure exei-ted  upon  the  hair  in  the  part  of  the  follicle, 
just  above  the  entrance  of  the  sebaceous  gland,  its  nar- 
rowest part  or  neck,  the  diameter  not  being  large 
enough  to  admit  of  the  escape  of  the  hair  and  the  se- 
baceous matter  at  the  same  time,  without  considerable 
squeezing,  so  that  the  sebaceous  matter  is  pressed  into 
the  hair.  It  is  probable  that  the  hair,  besides  being 
supplied  with  oil  by  the  sebaceous  glands,  secretes  a 
cholesterine  fat.  This  is  shown  by  the  investigations 
of  Liebreich  in  regard  to  lanoline. 

Muscles. — The  arrectores  pilorinn  muscles  pass 
under  and  around  the  sebaceous  glands,  to  be  inserted 
into  the  hair-follicle.  By  their  contraction  they 
straighten  the  direction  of  the  hair  bulb,  and,  in  conse- 
quence, erect  the  point  of  the  hair,  literally  causing  the 
hair  to  stand  on  end.  This  function  is  observed  in 
man  chiefly  in  the  occurrence  of  ^' goose  flesh,"  from 
the  action  of  cold.  The  contraction  of  these  muscles 
further  aids,  though  to  a  sHght  extent,  the  emptying 
of  the  sebaceous  glands. 


CHAPTEE  III. 

THE   HYGIENE   OF   THE   HAIR. 

Attention  to  the  care  of  the  hair  and  the  hairy 
scalp  is  of  special  importance  to  those  who  belong  to 
families  in  which  premature  baldness  is  hereditary, 
and  it  can  not  be  given  too  early.  We  should,  there- 
fore, instruct  the  parents  as  to  the  importance  of  giv- 
ing attention  to  their  children's  heads,  so  that  the 
matter  may  not  be  delayed  too  long,  and  the  hair  fall 
out  when  it  is  too  late  to  stop  it.  Dandruff  is  regarded 
by  most  people  as  merely  an  annoyance,  and,  if  not 
excessive,  is  neglected.  If  we  could  convince  the  laity 
that  dandruff  is  the  chief  cause  of  baldness,  they  would 
eagerly  seek  relief,  the  disease  could  be  early  checked, 
and  the  day  of  hair-fall  very  much  delayed,  The  care 
of  the  hair  is  important,  not  only  to  those  with  an  in- 
herited tendency  to  baldness,  but  to  all  who  wish  to 
preserve  their  hair  in  good  condition,  and,  if  properly 
attended  to,  it  will  be  a  prophylactic,  not  only  to  dis- 
eases of  the  hair  proper,  but  also  to  parasitic  troubles 
of  all  sorts.  It  is  true  that  this  demands  the  expendi- 
ture of  a  certain  amount  of  time,  but  it  is  time  well 
expended,  though,  I  must  confess,  often  greatly  be- 
grudged by  male  patients. 

The  hygiene  of  the  hair  and  scalp  consists  in  the 
proper  use  of  the  shampoo;  in  brushing  and  comb- 
ing; in  arranging  the  hair;  in  the  exposure  of  the 
hair  to  air  and  light;  in  cutting  and  shaving  it;  and 
in  the  use  of  pomades.  We  should  watch  over  the 
hair  from  earliest  infancy,  and  instruct  our  patients  as 
carefully  in  regard  to  its  hygiene  as  we  should  do  in 
regard  to  matters  of  general  hygiene. 


52  DISEASES   OF  THE   HAIR   AND   SCALP. 

Shampoo. — The  first  attention  that  the  hair  demands 
is  the  ridding  of  the  scalp  of  the  newborn  child  of  the 
vernix  caseosa.  This  is  the  fh'st  shampoo,  and  should 
be  more  carefully  performed  than  any  subsequent  one. 
Improper  management  at  this  time  may  entail  endless 
worry  to  the  mother  and  a  great  deal  of  suffering  to 
the  child,  as  it  is  exceedingly  likely  to  set  up  an  in- 
flammation of  the  scalp.  The  child  is  born  covered 
^Wth  a  fatty  matter  called  the  vernix  caseosa^  which 
is  often  very  thick  upon  the  scalp.  Steps  are  to  be 
taken  at  once  for  its  removal,  which  must  be  effected 
with  the  greatest  care,  and  with  the  avoidance  of  all 
force.  To  this  end  the  scalp  is  to  be  satm-ated  with 
sweet  almond  oil,  which  is  the  most  elegant  means;  or 
Avith  ohve  oil  or  vasehne.  It  is  preferable  to  use  these 
in  their  natural  state,  but  if  desired,  there  is  no  objec  • 
tion  to  perfuming  them  with  a  few  drops  of  the  oil  of 
bergamot,  T\intergTeen,  or  the  hke.  The  nurse  should 
do  this  immediately  after  she  has  washed  the  child's 
face  and  eyes.  Then  after  the  body  has  been  bathed 
and  the  infant  dressed,  she  should  wash  the  head  ^ith 
plenty  of  warm  water  and  soap,  such  as  pure  castile 
or  glyceiine  soap,  either  sohd  or  Hquid.  Tliis  should  be 
done  very  gently,  and  if  the  vernix  caseosa  is  not  readily 
removed,  she  should  re-apply  the  oil  and  wait  until  the 
next  day,  when  it  will  be  easily  washed  oif .  Should  it 
stiU  prove  obstinate,  let  her  patiently  repeat  the  process 
until  it  comes  off.  In  no  case  should  the  fine  toothed 
comb  be  used.  For  some  weeks  the  infant's  scalp  should 
be  lightly  oiled,  as  this  ^^'iU  prevent  any  accumulation  of 
sebaceous  matter,  and  protect  the  tender  skin  from  in- 
jury from  atmospheric  causes  until  the  hair  gi'ows, 
care  being  taken  to  wash  the  head  daily  to  prevent  the 
oil  from  becoming  rancid.  Wlien  the  hair  is  gro\\Ti 
the  scalp  need  not  be  so  often  oiled,  nor  should  it  be 
washed  more  than  once  or  twice  a  week. 


THE   HYGIENE   OF   THE   HAIR.  53 

In  children  and  adults,  the  scalp  should  be  kept  clean 
so  as  to  avoid  stopping  up  the  hair  follicles  with  foreign 
matter,  and  to  prevent  any  irritation  of  the  scalp,  which 
its  presence  might  cause.  This  is  accomplished  by  the 
systematic  use  of  the  shampoo  followed  by  careful  dry- 
ing, and  the  apphcation  of  some  oily  substance  to  the 
scalp.  It  may  be  given  as  a  rule,  that  a  shampoo  every 
second  to  fourth  week  is  sufficient  for  the  scalp  of  those 
who  are  not  exposed  to  more  than  the  usual  amount 
of  dust;  while  those  who  are  so  exposed  should  sham- 
poo the  head  every  week  or  two.  The  practice  of 
daily  sousing  the  head  with  cold  w^ater,  as  is  very 
commonly  done  by  men,  is  pernicious,  not  because  the 
water  itself  is  harmful,  but  because  the  scalp  is  not 
properly  dried  afterwards;  no  oil  is  applied  to  take  the 
place  of  the  oil  that  has  been  removed  by  the  water, 
the  wet  hair  cannot  be  thoroughly  brushed,  and  soon 
becomes  dry  and  brittle.  Women  avoid  getting  their 
hair  wet,  and  this  may  be  one  reason  why  they  are 
less  often  bald. 

The  proper  manner  of  shampooing  the  head  is  as 
follows:  Choose  some  good  soap,  such  as  Pears'  "  Gly- 
cerine Soap, "  Sarg's  ' '  Liquid  Glycerine  Soap, "  pure 
Castile  soap,  the  tincture  of  green  soap,  or  the  tincture 
of  prepared  olive  soap,  and  with  plenty  of  warm  water 
make  a  good  lather  on  the  head,  and  rub  the  head  vig- 
orously with  the  fingers,  or  Avith  a  rather  stiff,  long 
bristled  brush.  Another  excellent  liquid  soap  is  com- 
posed of  Castile  soap  eighty  parts,  bicarbonate  of  soda 
twenty  parts,  and  water  one  hundred  parts  (Pasch- 
Kiss,  134  ap.).  A  very  little  of  this  makes  an  abun- 
dant lather.  If  the  scalp  is  very  sensitive  to  irritants, 
borax  and  water  may  be  used  instead  of  soap,  or  a 
mixture  composed  of  the  yolks  of  three  eggs  beaten 
up  in  a  pint  of  lime  water.  When  the  head  has  been 
thoroughly  shampooed,  wash  out  the  lather  with  a 


54  DISEASES   OF   THE   HAIR   AND   SCALP. 

copious  supply  of  warm  water,  or,  where  practicable, 
with  alternate  douches  of  warm  and  cold  water,  and 
then  dry  both  scalp  and  hair  with  a  good  bath  towel. 
"VAHien  all  is  dry,  nib  on  the  scalp,  not  on  the  hair,  a 
small  quantity  of  some  unctuous  substance,  such  as 
sweet  almond  oil  or  vaseline.  Care  must  be  used  in 
drying  the  hair,  specially  in  women,  who  should  sit 
b.?f  ore  an  open  fire,  or  in  the  sunhght  when  doing  it,  and 
who  should  not  dress  the  liair  until  it  is  perfectly  dry. 
To  oil  the  scalj),  the  hair  should  be  parted  and  the  oil 
rubbed  in  along  the  part,  then  another  paii  made,  and 
the  operation  repeated,  and  so  on  till  the  whole  scalp  is 
gone  over.  In  using  a  fluid  oil  a  medicine-dropper 
will  be  found  convenient.  Should  there  be  an  excess 
of  oil  upon  the  hair,  a  condition  which  is  disagreeable 
to  many,  it  may  be  removed  readily  by  pulling  the 
hair  between  the  folds  of  a  towel  moistened  with  ether, 
chloroform,  or  cologne  water. 

Brushes  and  Brushing.— Of  far  more  importance 
than  shampooing  is  the  use  of  the  brush  and  comb, 
and  much  more  care  should  be  given  to  the  selection 
and  use  of  these  common  toilet  articles  than  is  usually 
bestowed.  Too  often  they  are  badly  made,  and  gener- 
ally, specially  with  men,  they  are  used  in  a  very  per- 
functory maimer.  The  brush  which  is  to  be  used  upon 
an  infant's  head  should  have  long,  soft  bristles,  so  as 
not  to  scratch  or  irritate  the  tender  scalp,  and  should 
l)e  employed  simply  in  smoothing  and  polishing  the 
hair.  For  young  children  whose  hair  is  well  grown,  a 
stiffer  brush  is  necessary,  and  for  adults,  two  brushes 
should  be  used,  a  stiff  one  and  a  soft  one.  A  properly 
made  brush  has  its  bristles  placed  in  httle  clumps  or 
groups  in  such  a  manner  that  the  middle  bristles  of 
each  group  are  longer  than  those  of  the  periphery. 
The  bristles  are  well  set  into  the  back  of  the  brush  and 
the  groups  are  A\ide  apart.     Most  of  the  brushes  met 


THE   HYGIENE   OF   THE   HAIR.  55 

with  in  the  shops  are  made  with  the  bristles  all  of  the 
same  length  and  the  groups  close  together  so  as  to  look 
pretty,  but  not  to  perform  their  proper  function.  The 
stiff  brush  should  be  used  systematically  in  the  morn- 
ing and  with  considerable  vigor,  so  as  to  produce  a  feel- 
ing of  warmth  in  the  scalp,  and  to  brush  out  all  pai'ti 
cles  of  dandruff  and  foreign  matter  lodged  in  the  hair. 
Every  part  of  the  scalp  should  be  gone  over  wuth  the 
stiff  brush,  and  then  it  should  be  laid  aside  for  the  rest 
of  the  day,  and  the  soft  one  used  to  assist  the  comb  in 
parting  the  hair,  and  to  give  smoothness  and  gloss  to 
it.  The  stiffness  of  the  brush  and  the  vigor  of  its  em- 
ployment must  vary  with  the  tenderness  of  the  scalp, 
and  in  no  case  should  be  sufficient  to  cause  a  feeling  of 
soreness.  Were  brushing  performed  in  the  manner 
indicated,  the  hair  w^ould  lie  properly  without  the  aid 
of  water  or  pomades,  excepting  of  course  in  cases  of 
malposition  of  the  hair,  as  in  the  so-called  cow-lick, 
or  where  the  hair  is  unnaturally  stiff. 

Combs  and  Combing. — The  comb  is  next  in  impor- 
tance to  the  brush,  its  office  being  to  open  up  the  hair 
so  that  the  brush  may  reach  all  parts  of  the  scalp,  to 
part  the  hair,  and  to  disentangle  snarls.  A  pioperly 
made  comb  has  long,  thick,  wide,  perfectly  smooth 
teeth,  with  well-rounded  ends,  and  set  wide  apart.  In 
choosing  a  comb  it  should  be  held  up  to  the  light,  and 
discarded  if  any  roughness  or  irregularities  are  found 
in  the  surfaces  of  its  teeth,  for  such  a  comb  w^ould  catch 
and  tear  the  hair.  Combs  are  usually  made  with  a 
coarse  and  a  fine  half,  and  there  is  no  objection  to  this 
arrangement  if  the  fine  pai-t  is  used  only  to  disentangle 
the  hair.  No  attempt  should  be  made  to  pick  off  crusts 
from  the  scalp  with  the  comb.  It  should  be  used  only 
as  an  assistant  to  the  brush,  and  always  with  it  in  the 
systematic  morning  brushing.  No  comb  should  touch 
an  infant's  scalp,  and  the  fine-toothed  comb  should  be 


56  DISEASES   OF  THE   HAIK   AND   SCALP. 

rigorously  excluded  from  the  toilet  case.  It  is  a  dan- 
gerous instmment,  the  cause  of  many  a  case  of  eczema, 
and  only  of  use  in  removing  the  ova  of  lice  from  the 
hair.  Ahove  all  things,  the  tender  scalp  of  the  infant 
should  be  spared  from  its  damaging  eifects. 

Dressing  of  the  Hair  of  "Womex. — Now  we  come 
to  a  place  in  the  discussion  of  the  hygiene  of  the  hair 
in  which  fashion  often  interferes.  Examination  of  old 
fashion  plates  and  portraits  will  show  how  women  and 
men  have  tortui-ed  the  hair,  twisting  it  into  all  sorts  of 
shapes,  and  smothering  it  imder  wigs,  false  hair  and 
powder.  Happily,  at  present,  the  hair  is  worn  more 
simply,  but  stiU  the  crimping  or  the  curhng  iron  is  too 
much  used,  and  the  hair  is  pulled  and  dragged  upon 
too  much  in  adapting  it  to  the  varying  demands  of  the 
hair- dresser.  Sooner  or  later  nature  is  apt  to  rebel 
against  fashion,  and  the  hair  grows  less  luxuriantly  or 
faUs  out.  The  simplest  mode  of  wearing  the  hair  is 
the  l:)est.  It  should  be  combed  and  brushed  smootlily 
back  upon  the  top  of  the  head,  either  parfed  or  not  as 
is  most  becoming,  and  gathered  into  a  loose  braid  or 
coil  at  the  back  of  the  head.  Girls  should  wear  a  pend- 
ant braid;  and  women  whose  hair  is  gTO^\'n  and  who 
gather  the  hair  into  a  coil,  should  use  large  hau'pins 
in  fastening  it,  preferably  of  rubber  or  bone,  ^yiih  abso- 
lutely smooth  surfaces.  In  doing  up  the  hair  care 
should  be  taken  not  to  drag  upon  it;  and  di-awing  it 
into  unnatural  ]:>ositions,  such  as  pulhng  the  hair  from 
the  back  of  the  head  over  forwards  to  near  the  fore- 
head, should  be  avoided.  If  a  woman's  hair  curls 
naturally,  she  should  be  thankful  for  the  favor  therein 
bestowed,  but  should  it  not  cuiI  of  itself,  she  should 
not  attempt  to  make  it  curl  by  singeing  and  squeezing 
it  between  hot  irons,  scorching  it  over  a  hot  pipe-stem, 
or  twisting  it  up  tightly  in  carl  papei'S. 

Wigs,  Hats,  etc. — The  hair  requires  for  its  growth^ 


THE   HYGIENE   OF  THE   HAIR.  57 

and  for  the  maintenance  of  its  health,  both  air  and  snn- 
light,  though  not  necessarily  exposure  to  the  direct 
rays  of  the  sun.  It  is  difficult  to  prove  that  wearing 
of  the  hat  constantly  is  a  cause  of  baldness,  but  there 
are  many  indications  that  such  is  the  case,  and  it  is 
well  to  avoid  keeping  the  head  covered  with  an  un ven- 
tilated hat.  If  the  occupation  compels  one  to  be  out 
of  doors  most  of  the  time,  or  exposed  to  draughts  so 
that  a  hat  or  cap  must  be  worn,  it  should  be  well  ven- 
tilated, so  that  the  heat  from  the  head  may  not  become 
confined,  and  the  hair  more  or  less  sweated.  The  sub- 
ject of  hats  as  a  cause  of  baldness  will  be  treated  of 
more  fully  under  Chapter  VI.,  upon  Alopecia.  The 
wearing  of  wigs  and  false  hair  is  bad  for  whatever  hair 
remains,  and  should  not  be  practiced.  The  absurd 
"  water-falls  "  of  a  few  years  ago,  and  the  no  less  ridi- 
culous  powdered  wigs  of  old  times  are  happily  things 
of  the  past,  and  should  never  be  revived.  If  a  woman's 
hair  is  short  and  scanty,  it  is  better  for  her  to  wear  it 
cut  short,  and  endeavor  to  stimulate  its  growth  by  at- 
tention to  the  scalp,  than  by  wearing  false  braids  to 
assume  a  beauty  which  she  has  not.  Wigs  heat  the 
head  and  sweat  tlie  hair.  False  hair  by  its  weight 
drags  upon  the  feeble  hair  it  is  designed  to  fortify. 

The  wearing  of  night-caps  was  once  a  custom, 
founded  upon  the  need  of  keeping  the  head  warm  in 
the  inadequately  heated  bedrooms  of  our  ancestors. 
With  the  improvement  in  house  building  and  heating, 
the  custom  has  passed  away,  and  should  not  be  re- 
vived, as  it  excludes  the  air  from  the  hair  continuously 
for  a  good  part  of  the  day.  Of  course  where  there  is 
no  hair,  and  the  bald  individual  is  sensitive  to  the  cold, 
there  can  be  no  objection  to  keeping  the  head  covered 
with  a  wig  by  day  and  a  cap  by  night. 

Hair  Cutting.— All  men  wear  the  hair  short,  and 
employ  a  barber  at  varying  intervals  according  to  their 


oS  DISEASES   OF   THE   HAIR   AND   SCALP. 

fancy.  As  far  as  the  health  of  the  hair  is  concerned, 
it  is  immaterial  whether  it  is  cut  at  longer  or  shorter 
intervals,  but  it  is  essential  that  it  should  be  well  cut, 
and  a  good  barber  is  desirable.  It  should  never  be 
"shingled,"  as  the  barbers  term  an  operation  which 
consists  in  cutting  the  hair  by  a  to-and-fro  motion  of 
the  shears,  as  this  tears  and  roughens  the  hair.  The 
hair  of  cliildi'en,  whether  they  be  boys  or  girls,  should 
be  kept  cut  shoi-t  until  the  seventh  or  eighth  year  of 
age,  as  the  growing  hair  is  a  drain  upon  the  nutrition 
of  the  body,  and  at  this  time  of  hfe  all  the  nutritive 
forces  should  be  expended  in  the  gro^\i;li  of  muscle  and 
bone.  The  hair  of  a  girl  after  she  has  reached  her 
eighth  year  should  be  allowed  to  grow,  as  the  less  the 
hair  is  cut  the  fuier  it  is.  But  should  the  girl  be  so 
situated  that  her  scalp  and  hair  can  not  be  properly 
cared  for,  then  she  will  have  a  better  chance  for  a  good 
head  of  hair  in  later  life  if  it  is  cut  when  she  is  young. 
The  hair  of  women  is  seldom  worn  shoi-t,  although  of 
late  some  young  women  have  seen  fit  to  adopt  the  style 
of  wearing  the  hair  hke  a  man,  along  with  his  coat  and 
waist-coat.  It  is  quite  common  for  the  long  hair  of 
women  to  be  split  at  the  point.  This  should  be  looked 
for,  and  if  found,  the  hair  should  be  cut  above  the 
cleft.  AU  ragged  ends  should  be  lopped  off,  and  all 
weak  hairs  should  be  cut  off  near  the  head. 

Shaving. — The  shaving  of  the  beard  is  regulated 
largely  by  fasliion.  Physiologically  it  is  best  not  to 
shave,  for  if  we  do,  we  rob  ourselves  of  a  useful  protec- 
tion to  the  throat  and  lungs.  As  shaving  makes  the 
hair  grow  coarser,  it  is  often  resorted  to  very  early  by 
the  youth,  for  the  purpose  of  rendering  the  do^^^l  of 
the  lip  or  cheek  more  apparent.  It  would  be  better  to 
endui'e  the  downi  for  a  time,  as  the  growth  of  an  ele- 
gant soft  beard  would  be  the  reward.  If  one  must 
shave,  he  should  do  it  himself,  and  see  that  Ms  razore 


THE  HYGIENE   OF  THE   HAIR.  59 

are  kept  sharp.  He  should  shave  himself,  so  as  to 
avoid  the  risk  of  infection  with  ringworm  of  the  heard. 
If  the  razors  are  dull,  they  are  apt  to  set  up  an  inflam- 
mation of  the  hair-follicles  or  skin.  For  shaving,  a 
mild  soap  that  forms  a  thick  lather  should  be  used, 
and  after  the  operation,  especially  in  cold  or  windy 
weather, the  face  should  be  powdered  with  simple  rice 
flour  or  fine  corn- starch. 

Pomades. — Punch's  advice  to  a  man  about  to  marry 
is  equally  applicable  to  the  use  of  pomades.  It  was: 
'^  Don't."  Their  regular  use  upon  the  healthy  scalp 
is  uncalled  for.  They  are  dirty,  soon  become  rancid, 
and  emit  a  foul  odor,  unless  this  is  covered  by  some 
strong  perfume,  and  they  soil  whatever  the  wearer's 
head  comes  in  contact  with.  If  the  rules  already  given 
are  followed,  the  hair  will  be  smooth  and  have  suffi- 
cient lustre  for  beauty  without  pomades.  If  the  scalp 
is  diseased,  the  proper  remedies  should  be  applied.  In 
the  following  pages  it  will  be  indicated  when  and  what 
pomades  should  be  used.  Most  of  the  greases  advertised 
for  the  cure  or  prevention  of  baldness  or  grayness  are 
useless,  and  some  harmful.  The  powers  of  some  have 
been  vaunted  upon  grounds  that  are  rather  absurd,  as 
for  instance  bear's  grease,  because  the  bear  is  weU  cov- 
ered with  hair.  ''  Bandoline  "  and  the  like  sticky  sub- 
stances, as  well  as  hair  dyes,  should  not  be  used,  as 
the  former  is  bad  for  the  hair,  and  the  latter  are  not 
infrequently  followed  by  loss  of  health  from  the  poisons 
they  contain. 

In  some  cases  the  hair  becomes  matted  together  in 
a  tangled  mass,  especially  that  of  women  during  pro- 
longed iUness.  From  whatever  cause  arising,  care  and 
patience  wiU  usually  enable  the  mass  to  be  unravelled 
and  the  hair  saved.  To  do  this  it  must  be  attacked  a 
little  at  a  time  with  oil,  soap  and  water,  and  the  fin- 
gers, and  picked  apart  and  combed  straight.    By  proper 


60  DISEASES   OF   THE   HAIR  AND   SCALP. 

care  the  condition  is  avoidable  in  most  cases.  It  would 
be  very  exceptional  when  a  patient  could  not  bear  the 
combing  of  the  hair  with  a  coarse  comb  once  a  day, 
follow^ed  by  plaiting  it  into  one  or  two  plaits.  When 
this  is  done  gently  and  quietly  it  will  prove  refreshing, 
and  w^ill  prevent  any  trouble  with  the  hair  during  con- 
valescence. If  it  camiot  be  done,  then  it  is  best  to  cut 
off  the  hair  to  one  half  or  one  third  of  its  length,  so 
that  it  will  be  less  hable  to  tangle. 

As  the  hair  sympathizes  with  the  general  health  of 
the  body,  the  latter  should  be  maintained  in  good 
condition  by  a  wise  conformity  to  the  laws  of 
health.  By  the  proper  combination  of  the  hygiene 
of  the  body  with  that  of  the  hair,  it  is  possible 
for  even  one  who  is  predisposed  to  premature 
baldness  to  ward  off  the  evil  day  for  years;  and 
one  who  comes  of  a  strong-haired  family  should, 
as  a  rule,  not  become  bald  or  have  any  essential  disease 
of  the  hair. 


f 


PAET  II. 

THE  ESSENTIAL  DISEASES  OF  THE  HAIR. 

Canities.—  Discolorations. —  Alopecia. —  Alopecia 

Areata. — Atrophia  Pilorum  Propria.— 

Hypertrichosis. — Trichiasis. — 

Sycosis. — Folliculitis 

Decalvans. 


CHAPTEE    TV. 


Synonyms. — Trichonosis  cana;  Trichonosis  discolor; 
Poliothrix  poliosis ;  Trichonosis  poliosis;  Trichosis 
poliosis;  Spilosis  poliosis;  Poliotes;  Whiteness  of  the 
hair;  Blanching  of  the  hair;  Atrophy  of  the  hair -pig- 
ment. 

Canities  may  be  congenital  or  acquired;  partial  or 
complete;  sudden  or  slow  in  its  onset.  The  most  com- 
mon form  is  the  acquired,  which  usually  begins  as  a 
graying  of  a  few  hairs,  and  proceeds  more  or  less  slow- 
ly till  it  affects  all  the  hair  of  the  head  and  face. 

Congenital  Canities  usually  occurs  in  the  form  of 
tufts,  sometimes  in  round  patches,  the  more  or  less 
white  hair  showing  conspicuously  among  the  normally 
colored  mass.  These  cases  are  rare,  but  in  some  fami- 
lies are  hereditary,  a  white  tuft  of  hair  occurring  in  a 
large  number  of  their  members.  Among  the  cases  of 
this  sort  is  that  reported  by  Godlee  (103),  who,  in  18S-1-, 
met  with  a  girl,  six  years  of  age,  who  had  a  patch  of 
white  hair  growing  from  a  white  patch  of  scalp.  The 
child's  mother  had  a  precisely  similar  patch,  and  stated 
that  it  had  occurred  in  two  of  her  sisters,  in  one  brother, 
in  her  father  and  paternal  grandfather.  One  of  her  sis- 
ters had  four  children,  all  of  them  girls,  similarly  af- 
fected. When  the  whiteness  of  the  hair  is  general,  it 
is  associated  with  delicate  pink  skin  and  eyes,  and  is 
part  of  that  condition  known  as  albinism. 

Acquired  Canities  may  be  premature  or  senile.  Most 
often  grayness  does  not  begin  before  the  thirty-fifth  or 
fortieth  year  of  age.  If  it  occurs  before  that  time,  it  may 


64  DISEASES   OF  THE   HAIR  AND  SCALP. 

be  considered,  for  convenience,  as  prematm^e;  if  after 
that  time,  as  senile.  Both  forms  are  exceedingly  com- 
mon, many  persons  becoming  quite  gray  between  the 
twentieth  and  twenty-fifth  year,  while  it  is  exceptional 
for  any  one  to  attain  the  age  of  fifty  T\ithout  more  or  less 
gi'ay  hair  on  the  head.  There  are  so  many  variations 
in  the  manner  of  turning  gray,  that  it  is  hard  to  give 
a  definite  rule;  but  the  hair  of  the  temples  usually 
changes  its  color  first,  then,  after  a  greater  or  less 
length  of  time,  that  of  the  vertex  and  whole  head. 
Sometimes  the  beard  is  the  first  to  whiten,  but  it  more 
commonly  follows  that  of  the  head.  The  hair  of  the 
pubes  and  the  axillae  is  the  last  to  turn  gray,  and  often 
it  escapes  entirely.  When  the  process  is  due  to  some 
passing  cause  it  may  cease  upon  the  removal  of  the 
cause,  and  cases  of  normally  colored  hair  growing  in 
after  the  fall  of  the  white  hair  have  been  noted.  A 
very  rare  instance  of  this  has  been  reported  to  me  by  Dr. 
J.  W.  Warxer  of  this  city.  The  case  was  well  kno\\Ti 
to  him,  and  was  one  of  relapsing  canities  affecting  a 
gentleman  living  in  Sharon,  Conn.  This  gentleman's 
hair  and  beard  changed  from  black  to  white,  and  back 
again  three  times  in  thirty  years.  The  change  from 
black  to  white  was  always  rapid,  while  that  in  the  re- 
verse direction  was  slow,  taking  some  five  years  for 
completion.  Then  would  come  a  pause  of  some  years 
when  the  color  was  normal,  and  then  it  would  become 
white  again.  During  all  the  thirty  years  his  health 
was  good,  he  was  able  to  attend  to  an  active  out-of- 
door  business,  and  never  used  any  hair  dye.  Isdell 
(104)  has  reported  the  case  of  his  father,  who, 
in  1861,  and  when  sixty- two  years  of  age,  had  per- 
fectly gi'ay  hair  on  his  head  and  beard,  while  in  1882, 
when  he  died  at  the  age  of  eighty-three,  his  hair  w^as 
of  its  natural  dark  color  A\'ith  the  excej^tion  of  a  few 
gray  hairs  on  the  temples.     This  case  is  of  the  same 


CANITIES,    OR  GRAYNESS  OF  THE  HAIR.  65 

order  as  those  of  a  new  growth  of  teeth  and  hair  in 
extreme  old  age.  While  instances  of  white  hair  be- 
coming normal  in  color  again  are  rare,  it  is  not  un- 
common for  the  grayness  to  remain  partial  and  appar- 
ently stationary  for  a  number  of  years.  Generally, 
however,  grayness  is  progressive  and  permanent, 
whether  it  is  premature  or  senile. 

The  hair  in  canities  is  usually  unchanged  except- 
ing in  color,  but  it  may  be  drier,  stiffer,  and 
even  coarser  than  normal.  As  a  rule,  there  is  no 
change  in  the  color  of  the  scalp.  Where  we  find 
gray  tufts  upon  pale  yellow  patches  of  scalp,  the 
disease  is  rather  vitiligo  than  canities.  The  change 
in  the  color  of  the  hair  takes  place  at  its  root  first.  It 
usually  changes  to  gray  on  account  of  the  mixture  of 
the  essential  color  of  the  hair  with  the  whiteness  pro- 
duced by  absence  of  pigment  and  the  presence  of  air. 
Exceptionally,  hairs  are  met  with  whose  point  and 
root  are  white,  and  the  intermediary  part  normal  in 
color  ;  or  the  point  and  root  normal,  and  the  interme- 
diary part  white  ;  or  the  distal  ends  are  gray,  and  the 
proximal  ends  of  normal  color.  The  last  variety  is  most 
often  due  to  splitting  of  the  end.  Gradually,  as  the 
pigment  becomes  more  and  more  deficient,  the  white 
color  gains  the  ascendency,  the  whole  hair  is  blanched, 
and  finally  becomes  of  a  yellowish  or  snowy  white. 
The  darker  the  original  color  of  the  hair,  the  more 
prone  it  is  to  turn  gray  ;  brunettes  are  more  often 
gray  than  blondes,  and  become  so  earlier  in  life. 
Canities  may  exist  for  years  without  alopecia,  as  there 
is  no  direct  connection  between  them.  In  the  senile 
form,  however,  alopecia  is  apt  to  come  on  as  another 
senile  change,  and  Landois  states  that  incipient  bald- 
ness usually  follows  senile  canities  in  from  one  to  five 
years.  Men  are  more  often  affected  with  canities  than 
are  women. 


e^  DISEASES   OF  THE   HAIR   AND   SCALP. 

Sudden  change  of  color  of  the  liair  from  its  normal  hue 
to  perfect  white,  has  been  too  well  authenticated  to  allow 
of  a  doubt  as  to  its  occmTence,  though  its  possibihty  has 
been  denied  by  good  authorities,  who  have  questioned 
the  correctness  of  the  obseiTations  reported.  But  both 
medical  and  lay  history  record  many  instances  of  the 
phenomenon,  and  several  recently  reported  cases  dem- 
onstrate its  possibihty.  Thus  Laxdois  (108),  in  ISGG, 
repoi-ted  a  case  observed  by  himself,  occurring  in  the 
person  of  a  man  thirty -five  years  of  age,  who  was  ad- 
mitted into  the  hospital  suffering  ^ith  dehrium  tre- 
mens. His  dehrium  took  the  form  of  great  terror 
whenever  any  one  approached  him.  On  admission  his 
hair  was  of  blonde  hue,  and  remained  so  up  to  the 
evening  of  the  third  day.  On  the  morning  of  the 
fourth  day,  the  hair  both  of  the  beard  and  scalp  was 
noticed  to  have  become  gTay.  Some,  of  the  hairs  were 
white  from  root  to  point,  some  only  at  their  points, 
some  only  at  their  roots,  while  some  were  blonde  and 
white  at  different  points.  Another  mteresting  case  of 
this  kind  was  reported  by  Raymond  (110)  in  1882.  The 
patient  was  a  French  woman,  thirty-eight  years  old, 
with  black  hair.  She  was  of  a  nervous  and  impres- 
sionable temperament.  In  July,  1881,  she  was  gi'eatly 
affected  on  account  of  parting  with  her  son,  and  for 
about  six  weeks  she  could  not  sleep.  In  Januaiy,  1882, 
she  was  utterly  prostrated  l>y  the  loss  of  a  large  sum 
of  money  on  the  Bourse,  and  since  then  had  been  ex- 
ceedingly nervous,  finding  it  impossible  to  remain  quiet 
in  any  position  for  any  length  of  time.  She  lost  her 
appetite,  could  not  sleep,  and  had  pains  in  various 
paiis  of  her  body,  especially  in  her  head,  shoulders  and 
tibiae.  These  pains  were  of  two  characters,  the  one 
constant,  and  the  other  neuralgic  and  lancinating.  On 
the  head  and  face  there  were  various  painful  points. 
"VMien  she  received  the  news  of  her  loss  she  was  men- 


CANITIES,    OK  GRAYNESS  OF  THE   HAIR.  67 

struating,  and  the  flow  was  immediately  suppressed. 
On  January  31st  she  had  a  terrible  attack  of  neuralgia. 
By  two  o'clock  in  tlxO  morning  of  February  Is^  her 
hair  was  of  normal  color,  at  seven  o'clock  it  was  al- 
most completely  discolored.  Upon  the  sides  of  the 
head  the  color  was  preserved  in  part;  upon  the  upper 
portion  most  of  the  hair  was  fiery  red.  The  remainder 
of  the  hair  had  become  completely  white.  The  hair 
on  the  rest  of  the  body  was  unaffected.  The  pains 
still  continued.  On  the  next  day  most  of  the  red  hair 
had  become  white,  and  was  rapidly  falling.  In  fifteen 
days  nearly  all  the  hair  had  fallen  out,  only  a  few  hairs 
remaining  on  the  lateral  and  occipital  regions.  Up  to 
the  thirtieth  of  March  there  was  no  return  of  the  hair, 
nor  of  the  color  in  those  remaining. 

Ringed  Hair. — Ringed  hair  is  an  anomalous  variety 
of  blanching  of  the  hair,  in  which  the  affected  hairs 
are  marked  by  alternate  rings,  one  ring  having  the 
normal  color,  and  the  next  one  being  white.  This  dis- 
ease is  of  very  rare  occurrence,  and  but  few  cases  have 
been  reported.  Wilson  (122),  in  18(37,  reported  a  case 
of  this  kind,  which,  I  believe,  is  the  first  on  record.  The 
patient  was  a  boy  between  seven  and  eight  years  of 
age;  the  disease  was  fii'st  noticed  when  he  was  between 
two  and  three  years  old,  and  was  increasing.  It  af- 
fected only  the  head.  The  hair-cylinder  was  uniform, 
the  brown  or  normal  segments  measured  ^\-  of  an  inch 
in  length,  and  the  white  segnients  were  about  one  half 
as  long. 

Under  this  name  Lesser  (110)  reported  another  case 
in  1885.  This  occurred  also  in  a  child  four  and  a  half 
years  old,  otherwise  healthy.  It  was  born  entirely 
without  hair,  excepting  its  eyebrows,  which  were  nor- 
mal. Soon  after  birth  the  scalp  presented  the  appear- 
ance of  goose  flesh,  which  continued.  The  hair  began 
to  grow  by  the  second  yc'ar.     At  time  of  presenta- 


68  DISEASES  OF  THE  HAIR  A^T)   SCALP. 

tion  of  the  case,  there  was  observed  a  lichen  pilaris 
appearance  alorjg  the  border  of  the  hair,  on  the  neck 
and  temples.  The  hair  of  the  whole  head  was  extra- 
ordinarily  short,  measuring  even  after  two  years 
growtli,  from  1  to  9  cm. ;  it  was  dry  and  brittle  and 
inclined  to  tangle.  The  color  was  brown.  The  longer 
hairs  were  normal.  The  short  hairs  were  ringed  in 
gi'eat  part,  and  microscopically  showed  alternate  swell- 
ings and  contractions  of  the  shaft,  the  former  being 
spindle-shaped  and  forming  the  hght  or  white  ring  by 
dh'ect  light.  The  distance  between  the  contractions 
averaged  0.6  cm.  On  a  gieat  number  of  the  ringed 
hairs  there  were  appeai-ances  characteristic  of  moni- 
lethrix, to  which  disease  this  case  more  properly  be- 
longs. 

Etiology  and  Pathology. — Senile  canities  and 
most  cases  of  the  premature  or  presenile  form,  are  due 
to  an  obscure  change  in  the  nutrition  of  the  hair-papil- 
la, which  interferes  with  the  production  of  pigment. 
Whatever  the  nature  of  the  change  may  be,  only  this 
function  of  the  papilla  seems  to  be  interfered  with,  as 
the  hair-forming  function  is  in  normal  activity,  judging 
from  the  fact  that  the  hair  in  many  cases  is  in  full 
vigor.  Ehrmann  (101),  on  the  other  hand,  holds  that 
the  pigment  is  formed  in  the  papilla,  but  fails  to  reach 
the  hair  on  account  of  absence  of  certain  cells  in  the 
hair-root,  Avhich  he  believes  are  the  active  agents  in 
transferring  the  pigment  from  the  papilla  to  the  hair. 
His  views  are  given  more  fully  m  the  chapter  on  Phy- 
siology of  the  Hair.  According  to  Pixcus  (113),  in  the 
beginning  of  canities  the  pigment  slowly  leaves  the 
middle  layers  of  the  papilla  and  remains  only  in  the 
external  layers.  With  the  increase  of  the  canities, 
only  a  portion  of  the  external  layers  of  the  papilla  will 
produce  pigment,  which  in  straight  hair  will  ran  in 
streaks  parallel  to  the  long  axis,  and  in  curly  hair  will 


CANITIES,    OR  GRAYNESS   OF  THE   HAIR.  09 

n  1 11  in  a  spiral.     The  blending  of  the  colored  and  un- 
( .lored  streaks  will  produce  the  gray  color,  which  will 
gradually  change  to  white  as  the  pigment  is  less  and 
less  produced. 

Our  study  of  the  physiology  of  the  hair,  has 
taught  us  that  the  color  of  the  hair  (see  page  42)  ; 
is  very  much  influenced  by  the  amount  of  air  con-  / 
tained  in  the  cortex.  In  cases  of  sudden  blanch- 
ing of  the  hair,  the  change  of  color  is  dependent  upon 
the  formation  of  air-bubbles  between  the  hair-cells  of 
the  cortex,  its  presence  rendering  the  cortical  sub- 
stance opaque  and  obscuring  the  color  of  the  pigment. 
This  is  proven  by  placing  one  of  the  affected  haii's  in 
liot  water,  ether,  or  turpentine,  when  the  air-bubbles 
iwill  be  driven  out  and  the  hair  will  resume  its  normal 
color.  This  same  infiltration  of  the  hair  with  air-bub- 
bles will  be  found  also  in  cases  of  ordinary  canities, 
though  usually  merely  secondary  to  some  interference 
with  pigmentation. 

TJiere  are  various  agencies  which  act  as  predisposing 
or  exciting  causes  of  canities.  Age  or  senility  is  one 
of  the  most  prominent  of  these.  Heredity  exerts  a 
marked  influence,  most  of  the  members  of  certain 
families  turning  gray  at  an  early  period  of  hfe.  That  A 
the  nervous  system  works  actively  in  the  production 
of  grayness,  is  shown  by  the  occurrence  of  sudden 
l)lanching  of  the  hair  under  the  influence  of  fear  or 
gi-eat  nervous  shock;  by  the  formation  of  symmetrical 
'white  bands  or  tracts  of  hair  during  acute  outbreaks 
I  of  insanity,  which  disappear  during  convalescence,  as 
noted  by  Shaw  (IIT)  ;  and  by  the  hair  becoming  white 
in  parts  affected  by  neuralgia,  as  of  the  fifth  nerve- 
Hence  canities  may  be  regarded  as  a  tropho-neurosis  in 
^oiue  instances. 

Local  diseases  or  injuries   of    the   scalp,   such    as 
wounds,  repeated  epilation,  prolonged  shaving,  have 


70  DISEASES  OF  THE   HAIR  AXD  SCALP. 

been  known  to  have  local  or  general  canities  fol- 
low them.  The  hair  after  alopecia  areata  comes  in 
white  and  may  remain  so,  but  usually  the  wliite  haii-s 
fall  out  to  be  replaced  by  normal  colored  ones.  Wal- 
jj^XBERG  (119)  reports  a  case  of  entu-e  loss  of  hair  after 
scarlatina,  in  which  the  new  hair  came  in  white  and 
remained  so,  the  skin  at  the  same  time  losing  its  pig- 
ment, and  becoming  milk  white.  In  this  case  there 
was  a  good  deal  of  ah-  in  the  cortex.  The  hair  has 
been  known  to  turn  gi^ay  in  winter,  and  to  become 
darker  in  summer.  Prolonged  residence  with  much 
exposure,  either  in  a  cold  or  hot  chmate,  is  given  as  a 
cause  of  premature  grayness.  Albinoes,  we  know,  are 
most  frequent  in  the  negro  races,  which  inhabit  the 
hot  countries.  On  the  other  hand,  Holder  {124:  ap.) 
says  that  gray  hair  is  very  rare  amongst  the  Ameri- 
can Indians.  Excessive  mental  application,  or  pro- 
longed nervous  strain,  will  sometimes  induce  canities, 
which  becomes  permanent  and  progressive.  In  like 
mamier  dyspepsia  of  various  forms,  excesses  of  aU 
kinds,  chronic  debihtating  diseases  such  as  syphihs, 
malaria  and  phthisis,  i)rofuse  and  frequent  hemor- 
rhages, have  been  given  by  various  writers  as  causes  of 
canities.  It  has  been  noted  that  in  women  who  early 
cease  to  menstruate  the  hair  is  apt  to  become  prema- 
turely gray,  while  those  who  menstruate  late  in  life 
often  retain  the  color  of  their  hair.  In  this  as  in  many 
other  diseases,  no  one  cause  or  group  of  causes  can  be^ 
proven  to  be  the  cause,  but  a  study  of  those  given  w 
siiow  that  they  have  one  thing  in  common,  that  is,  a 
lowering  of  vitality. 

The  curious  phenomenon  of  '^  ringed  hair"  is  ascribed 
by  Wilson  (122)  to  the  development  of  a  gaseous  fluid 
within  the  hair,  and  he  thinks  that  either  the  white, 
opaque  and  smaller  segments  were  developed  during 
the  night,  and  the  larger  and  normal  segments  grew  i 


beJ 


n 

during  the  day,  or  the  separate  segments  were  the  pro- 
duct of  alternate  days.  The  gas  may  have  been  gener- 
ated at  the  time  of  the  formation  of  the  abnormal  seg- 
ment, or  the  cells  which  composed  that  segment  may 
have  been  originally  filled  with  an  aqueous  fluid,  which 
evaporated  quickly,  and  was  replaced  by  air  penetrat- 
ing from  without.  Landois  (109)  does  not  agree  with 
Wilson,  but  believes  that  we  must  assume  an  inter- 
mittent activity  of  the  trophic  or  vaso-motor  nerves  of 
the  papillae,  through  whose  influence  a  hair  tissue  is 
formed,  in  which  a  periodic  development  of  gas  takes 
place.  Lesser  (110),  in  whose  case  the  hair-shaft  was 
affected  with  trichorrhexis  nodosa,  likewise  found  air- 
bubbles  in  the  white  or  swollen  parts,  which  gained 
entrance  from  without  through  the  dry  and  cracked 
cuticle  of  the  hair.  He  offers  no  explanation  for  the 
intermittency  of  the  rings.  In  his  case  there  was  evi- 
dently some  error  in  the  nutrition  of  the  scalp.  Beh- 
REND  (3)  regards  the  disease  as  a  stage  of  trichorrhexis 
7iodosa,  and  says  that  the  process  affects  already 
formed  hair.  As  yet  no  answer  can  be  given  to  the 
question,   ^'  What  gives  rise  to  ringed  hair  ?" 

Treatment. — As  a  rule  nothing  can  be  done  to  per- 
manently restore  the  color  to  white  or  gray  hair.  If 
the  malady  is  due  to  neuralgia,  the  cure  of  this  will 
sometimes  be  followed  by  restoration  of  color.  The 
administration  of  iron,  phosphorus,  and  sulphur,  has 
been  advised  on  theoretical  grounds,  and  may  be  tried 
if  the  canities  seems  to  be  due  to  physical  debility;  but 
no  f)romise  of  success  should  be  made  to  the  patient. 
As  cases  have  been  reported  in  which  the  hair  has 
grown  darker  under  the  long-continued  use  of  jabo- 
randi  by  the  mouth,  or  pilocarpine  subcutaneously, 
these  drugs  might  be  tried.  Acetic  acid  also  seems  to 
have  a  decided  tendency  to  increase  the  pigmentation 
of  the  hair,  and  might  be  tried.     The  rules  of  the 


72  DISEASES -OF   THE  HAIR  AND   SCALP. 

hygiene  of  the  scalp  should  be  at  the  same  time  en- 
forced. Plucking  the  white  hairs  is  worse  than  use- 
less. All  that  can  be  done  for  canities  is  to  artificially 
restore  the  color  by  means  of  hair  dyes,  and  their  use 
is  to  be  strongly  advised  against.  Happily  the  custom 
of  dying  the  hair  is  falling  out  of  fashion. 

Hair  Dyes. — Hebra  and  Kaposi  (15)  give  directions 
for  dyeing  the  hair  black  by  ''henna,"  which  is  the  Per- 
sian name  for  a  small  shrub  found  in  the  East  Indies, 
Persia,  the  Levant,  and  along  the  African  coasts  of  the 
Mediterranean,  where  it  is  frequently  cultivated.  The 
botanical  name  is  Laivsonia  Alha ;  in  England  it  is 
called  Egyptian  privet,  and  in  the  West  Indies  it  is 
known  as  Jamaica  mignonette.  In  the  East  it  is  used 
for  dyeing  red  the  nails  of  women,  the  lieards  of  men, 
and  the  manes  of  horses.  The  preparation  of  hemia 
consists  in  reducing  the  leaves  and  yomig  twigs  to  a 
fme  powder,  catechu  or  lucerne  leaves  in  a  pulverized 
state  being  sometmies  mixed  with  them.  Wlien  re- 
quired for  use  the  powder  is  made  into  a  pasty  mass 
with  hot  water,  and  then  spread  upon  the  part  to  be 
dyed.  *  In  an  hour  the  hair  will  be  red.  A  paste  of  pow- 
dered indigo  plant  is  now  applied,  and  then  damp  heat, 
and  in  a  few  hours  the  hair  will  have  a  fuie  black  color, 
provided  that  the  process  has  been  regulated  by  expe- 
rience and  good  judgment.  Leonard  ((U)  gives  the 
foUo\\ing  formula?  for  dyeing  the  haii*  black: 


iS'o.  1 

. 

Bismuthi  citratis  . 
Alcohohs 

!j  =          50 

3  v  =          33 

AquiB  rosre 
Aqua?  destillat.      . 
Ammoniae 

.     aa  3  ij  =  ad  200 
q.s. 

M.  Sig.     Api)ly  in  the  : 

morning 

*  Encyc.  Brit.,  9th  ed.,  art.  HeniKU 


,       CANITIES,  OR  GRAYNESS  OF  THE   HAIR.  73 

No.  2. 

Sodii  hyposulphit.     .         3  xii  =  60 

Aquae  destillat.    .        .         3  iv  =  ad  200. 

M.  Sig.     Apply  thoroughly  in  the  evening. 

Nitrate  of  silver  in  the  strength  of  from  five  to  ten 
grains  to  the  ounce  of  water  may  be  used  for  a  black 
dye,  the  hair  being  saturated  with  it  and  allowed  to 
dry  in  the  sunHght.  If  it  is  desired  to  hasten  the  pro- 
cess, the  application  of  a  solution  of  sulphuret  of  pot- 
ash, from  twenty  grains  to  two  drachms  to  the  ounce 
of  distilled  water,  will  set  the  dye  instantly.  McCall 
Anderson  recommends  the  following  for  a  permanent 
black  dye:  First,  a  solution  of  bichloride  of  mercury, 
two  grains  to  the  ounce  of  water,  followed  by  a  solu- 
tion of  hyposulphite  of  soda,  one  drachm  to  the  ounce 
of  water.  Lead  may  be  used  in  the  form  of  the  sugar 
of  lead,  ten  to  twenty  grains  to  the  ounce  of  water, 
apphed  to  the  hair  and  followed,  when  nearly  dry,  by 
a  solution  of  the  sulphide  of  ammonia,  about  one- 
quarter  the  strength  of  the  British  Pharmacopoeia. 
These  dyes,  by  means  of  nitrate  of  silver  and  mer- 
cury, are  dangerous  on  account  of  the  metals  they  con- 
tain. 

For  a  brown  dye,  Pfaff  (70)  recommends  a  pomade 
composed  as  follows: 

01.  ovorum  rec.  press. 

Med.  OSS.  bovis      .        .        .aa  50. 

Ferri  lactat 2.50. 

01.  cassias  ether.    .        .        .        1.50. 
M. 

But  the  number  of  dyes  is  legion,  and  these  must 
suffice  for  examples.  Before  the  application  of  any 
dye,  the  hair  should  be  thoroughly  cleansed  with  ssoap 
and  water. 


CHAPTEE   V. 

DISCOLORATION  OF  THE  HAIR. 

Synoxyms. — Tricolorosi.  Trichonosis  seu  Trichosis 
decolor. 

Under  various  conditions  of  health  and  disease, 
the  hair  has  been  known  to  undergo  changes  in 
color,  other  than  that  of  turning  gray.  Some  of  these 
changes  depend  upon  causes  acting  from  within,  and 
modifying  in  some  way  the  pigment  formation.  Some 
are  due  to  external  agencies,  and  have  the  nature  of 
dyes. 

Just  as  serious  ilhiess  will  cause  the  hair  to  fall  out 
or  to  turn  gray,  so  will  it  induce  changes  in  color. 
Some  instances  of  this  have  been  reported.  Thus 
Rayer  (31)  cites  two  cases  of  Alibert's,  in  the  first  of 
which  a  young  woman  after  a  long  and  serious  illness 
lost  a  fine  head  of  blonde  hair,  and  upon  recovery  had 
the  loss  made  good  by  a  gro^%i:h  of  very  black  hair.  In 
the  second  case,  a  man  during  sickness  lost  his  brown 
hair,  which  was  replaced  after  recovery  by  bright  red 
hair.  He  further  cites  a  curious  case  in  which  every 
time  the  patient,  a  young  woman,  was  attacked  with 
f(3ver,  her  blonde  hair  became  ta^\my  red,  to  return  to 
its  original  hue  upon  recovery.  Beigel  (123)  reports 
a  case  in  which,  after  typhus  fever,  the  blonde  hair  of 
a  woman  feU  out,  and  was  replaced  by  coal  black  hair. 
Smyly  (136)  saw  the  hair  of  a  patient  suffering  with 
suppurative  disease  of  the  left  temporal  bone,  change 
from  a  mouse  color  to  a  reddish  yellow.  The  patient 
was  an  infant.  The  left  temporal  bone  was  the  seat  of 
the  suppuration,  but  the  right  side  of  the  head  was 


DISCOLORATION  OF  THE  HAIR.  Y5 

affected  with  the  change  in  color  of  the  hair.  The 
right  eyebrow  was  Hkewise  affected.  There  was  also  a 
profuse  yellow  perspiration,  so  that  the  pillow  and  the 
skin  of  the  right  side  were  stained  yellow.  This  case 
was  one  of  dyeing.  C.  Eeinhard  (135)  has  reported  a 
case  of  periodic  change  in  the  color  of  the  hair  of  an 
idiot  boy  who  suffered  with  epilepsy  and  paralysis  of 
the  legs.  He  was  subject  to  violent  outbursts  of  tem- 
per, during  which  his  reddish-blonde  hair  would  change 
in  forty-eight  to  sixty  hours  to  a  blonde  yellow  color. 
The  change  of  color  seemed  to  begin  at  the  points  of 
the  hair,  and  affected  nearly  all  the  hair.  After  some 
seven  or  eight  days,  the  original  color  would  return. 
There  was  no  disease  of  the  scalp,  excepting  that  dur- 
ing the  stage  of  quiet,  there  was  a  scanty  secretion  of 
sebaceous  matter.  Microscopical  examination  showed 
that  the  light  hairs  contained  a  good  deal  of  air  in  the 
cortex  and  medulla;  that  they  were  dry  and  inclined 
to  split  at  their  points.  Their  cuticle  cells  were  dis- 
placed; and  the  medulla  cells  were  very  much  shrunken. 
This  would  be  sufficient  to  explain  the  change  of  color, 
as  our  study  of  the  physiology  of  the  hair  has  already 
taught  us. 

That  it  may  be  possible  to  influence  the  color  of  the 
hair  by  internal  medication,  is  inferred  from  the  re- 
markable case  reported  by  Prentiss  (134).  He  had  a 
patient  with  light  blonde  hair  who  suffered  f i*om  i)yelo- 
nephritis  with  anuria,  for  the  relief  of  whicli  condition 
muriate  of  pilocarpine  was  administered  hypodermi- 
cally  in  doses  of  from  0.01  to  0.02  gi-amme.  The  use 
of  the  drug  was  begun  on  December  10,  1880,  and  the 
hair  commenced  to  grow  darker  by  the  twelfth  day. 
On  the  twelfth  of  January,  1881,  the  color  had  become 
chestnut  brown,  and  by  the  first  of  May  it  was  almost 
pure  black,  although  the  pilocarpine  was  stopped  on 
the  twenty-second  of  February.     The  hair  became  not 


^6  DISEASES   OF  THE  HAIR  AND  SCALP. 

only  darker,  but  coarser,  and  grew  more  vigorously; 
and  the  hair  of  the  axillas  was  as  much  changed  as  that 
of  the  head.  The  hair  was  in  every  respect  normal, 
and  the  change  in  color  seemed  to  depend  upon  increase 
of  pigment.  With  the  change  of  color  in  the  hair,  the 
color  of  the  eye  changed  from  a  light  to  a  dark  blue. 
The  same  author  (101  ap.)  has  reported  another  case 
in  which  a  patient  with  Bright's  disease  took  from 
twenty  to  thirty  drops  of  fluid  extract  of  jaborandi 
several  times  a  day.  After  a  year's  treatment  his  hair 
turned  of  much  darker  color.  These  cases  would  tend 
to  show  that  jaborandi  increases  the  nutrition  of  the 
hair  and  the  activity  of  the  pigment-forming  cells. 
It  would  appear  that  the  cause  of  the  change  of  color 
was  the  jaborandi,  because  the  tendency  of  exhaust- 
ing diseases,  such  as  pyelonephritis  and  Bright's  dis- 
ease, is  rather  towards  loss  of  hair  and  canities.  Jabo- 
randi does  increase  very  markedly  the  cutaneous 
circulation,  and  to  this  action  we  must  look  for  the 
explanation  of  these  cases. 

We  have  no  means  of  explaining  with  certainty 
these  changes  of  the  hair  from  internal  causes.  Of 
course  they  are  due  to  some  influence  upon  the  pig- 
ment-forming cells,  but  that  does  not  explain  the  mat- 
ter. The  cases  reported  are  few,  and  only  in  those  of 
Prentiss  and  Smyly  does  an  adequate  explanation  sug- 
gest itself.  The  other  changes  in  color  of  the  hair,  the 
consideration  of  which  falls  within  the  scope  of  this 
chapter,  are  dependent  either  upon  a  deposition  of 
colored  particles  from  without,  or  upon  chemical  action. 
From  these  causes  we  have  green,  blue  and  yellow  hair, 
as  well  as  various  anomalous  shades. 

Green  Hair. — Green  hair  occurs  in  workers  in  cop- 
per. A  number  of  cases  have  been  reported ;  the  fol- 
lowing one  by  Petri  (132)  will  serve  as  an  example. 
An  old  worker  in  copper,  seventy-eight  years  of  age, 
presented  the  curious  appearance  of  having  briUiant 


DISCOLORATION  OF  THE  HAIR.  77 

green  hair.  He  was  in  good  general  health.  Upon 
his  gums  was  a  well-marked  green  line.  Both  his  beard 
and  scalp  hair  were  green.  The  color  did  not  affect 
the  whole  length  of  the  hair,  but  was  darkest  and 
most  intense  at  the  point,  and  for  a  distance  of  3  cm. 
therefrom.  From  that  point  it  grew  gradually  less 
pronounced,  till  at  10  cm.  it  had  disappeared.  Be- 
yond this  the  hair  was  gray.  The  microscopical  ex- 
amination of  the  green  hairs  showed  a  deposit  upon 
the  epidermis  of  the  hair,  of  small,  sometimes  bluish, 
sometimes  indefinitely  colored,  sometimes  darkly  con- 
toured or  yellowish,  sharply  cornered,  pyramid- shaped 
masses  of  crystals,  with  transparent  edges  Here  and 
there  little  patches  of  dirt  were  found.  The  crystals 
could  be  seen  only  with  very  strong  light.  By  the  ad- 
dition of  liquor  amnion,  caust.,  the  color  changed  to 
dark  or  blackish  blue,  which  is  the  chemical  reaction 
of  ammo^na  with  the  salts  of  copper.  The  color  could 
be  washed  out  of  the  hair,  and  was  doubtless  due  to 
particles  of  copper  oxide  floating  in  the  atmosphere  of 
the  work-shop,  and  deposited  on  the  haii".  Billi  (124:) 
reports  a  case  of  green  hair  occurring  in  a  patient  of 
his,  whom  he  was  treating  for  trichophytosis  capitis. 
For  the  ringworm  a  wash  of  corrosive  sul)limate  was 
ordered,  and  an  ointment  of  the  yellow  oxide  of  mer- 
cury. The  next  time  he  was  seen  his  hair  was  a  bril- 
liant green,  the  color  being  disseminated  over  the  whole 
head,  and  the  hair  colored  from  bulb  to  tip.  The  mi- 
croscope showed  that  all  the  elements  of  the  hair  were 
colored.  The  patient  was  not  a  worker  in  copper,  nor 
had  he  used  any  other  application  to  his  scalp.  Cases 
of  green  hair  have  been  reported  in  which  no  cause  was 
discoverable.  Thus  Orsi  (131)  met  with  a  case  in  a 
railroad  hand,  who  was  forty-nine  years  old,  and  whose 
hair  was  gray.  Suddenly  his  hair  became  green,  the 
green  hairs  being  intermixed  with  the  gray  and  white. 
The  scalp  hair  alone  was  affected.     Washing  with  vin- 


78  DISEASES   OF  THE   HAIR  AXD   SCALP. 

egar,  ether,  alcohol  or  a  dilute  solution  of  potash,  did 
not  affect  the  color.  The  microscope  showed  that  the 
roots  of  the  affected  hairs  were  thick  and  fihrous;  the 
coi*tex  by  natural  light  was  violet,  by  artificial  fight 
gi^eenish  in  color;  while  the  medulla  was  yefioTvfish. 
When  the  hair  was  cut  off,  gray  hair  grew  in.  Even 
in  this  case,  since  the  hair  came  in  of  normal  color, 
there  was,  doubtless,  some  external  agency  at  work. 
In  some  cases  of  canities,  a  greenish  yeUow  tint  wiU 
be  observed,  a  transition  stage  from  the  original  color 
to  the  gray,  and  tlfis  also  might  be  an  explanation  of 
the  foregoing  case. 

Blue  Hair. — Blue  hair  is  met  T\ith  in  workers  in 
cobalt  mines  and  in  indigo  works.  The  color  is  gener- 
afiy  easily  removed  by  waslung,  and  under  the  micro- 
scope Beigel  (123)  found  in  a  case  of  his  own,  that  the 
whole  hair  was  not  uniformly  colored,  but  that  particles 
of  indigo  were  deposited  in  an  UTegular  manner  upon 
the  cuticle  of  the  hair.  In  some  exceptional  specimens 
a  number  of  hairs  were  embedded  for  some  distance 
in  a  mass  of  indigo,  or  stuck  with  neighboring  hairs. 
The  edges  of  the  epithelial  scales  were  more  pronounced 
than  in  the  normal  condition,  owing  to  the  deposit  along 
them  of  a  fine  blue  dust.  The  blue  color  did  not  pene- 
trate into  the  substance  of  the  hair. 

Yellow,  Browx,  and  Black  Hair. — Yellow  hair 
has  been  observed  in  patients  suffering  from  icterus  ; 
red-brown  hair  occurs  in  handlers  of  crude  aniline ; 
and  black,  or  rather  coal-black,  hair  is  often  seen  on 
those  who  work  in  coal.  In  all  these  cases  of  change 
in  color  of  the  hair  from  the  deposit  of  foreign  matter, 
the  element  of  time  was  marked,  and  the  lighter  the 
color  of  the  hair  was  originally,  the  easier  did  it  become 
altered. 

Change  of  Color  after  Death. — The  color  of  the 
hair  may  change  after  death.  Thus  Hauptmaxn  (127) 
reports  a  case  in  which  the  hair  of  a  corpse,  exhumed 


DISCOLORATION  OF  THJ:  HAIR.  79 

after  twenty  years'  burial,  was  found  to  have  changed 
from  a  dark  brown  to  a  red  color. 

Color  altered  by  Chemicals. — The  action  of  vari- 
ous chemical  agents  will  change  the  color  of  the  hair, 
the  change  generally  being  transitory.  This  is  illus- 
trated by  the  action  of  the  various  dyes  and  bleaching 
fluids  used  by  the  hair-dresser.  Further,  bicarbonate 
of  sod^,  used  for  a  long  time,  will  change  the  color  of 
dark  hair  to  a  dirty  red  brown.  Chrysarobin  colors 
the  hair,  as  well  as  the  skin,  a  mahogany  red.  Naph- 
thol  I  have  seen  change  white  hair  to  a  bright  corn- 
yellow  color.  Chlorine  gas  will  bleach  the  hair. 
Sweat  acts  upon  the  color  of  the  hair,  and  we  often 
find  the  hair  of  the  axillae  of  persons  who  sweat  much 
of  lighter  color  than  that  of  the  head.  Leonard  (64) 
cites  a  case,  in  which  the  brown  head  hair  of  a  young 
man  turned  to  a  positive  red  after  a  few  years'  resi- 
dence in  the  hot  climate  of  Sumatra.  It  is  not  uncom- 
mon for  the  color  of  the  hair  to  grow  darker  or  lighter 
under  the  influence  of  exposure  to  sunlight. 

Anomalous  Cases. — In  some  cases,  according  to 
Oesterlen  (130),  hair  will  be  met  with  which 
is  more  intensely  pigmented  towards  its  root  than 
towards  its  point,  depending  upon  an  irregular 
deposit  of  pigment,  or  alteration  in  the  texture  of 
the  hair.  One  of  the  most  curious  anomalies  is  re- 
ported by  Squire  (137)  as  occurring  in  a  young  man 
sixteen  years  old,  the  left  side  of  whose  head  was  pie- 
bald like  a  tortoise-shell  cat.  The  condition  dated  from 
birth,  and  there  was  no  assignable  cause.  The  light- 
colored  patches  were  auburn,  the  dark  patches  brown, 
and  they  were  abruptly  hmited.  The  opposite  or  right 
side  of  the  head  was  covered  with  dark-brown  hair,  of 
the  same  tint  as  the  dark  patches  on  the  left  side.  The 
curious  condition  known  as  ringed  hair  will  be  found 
described  in  the  chapter  on  Canities  in  this  work. 


CHAPTEE    YI. 

ALOPECIA. 

Derivation. — The  term  is  derived  from  the  Greek 
word  dXGOTtrjC^  meaning  a  ^^fox,"  on  account  of  its  re- 
semblance to  the  appearance  presented  in  the  "fox- 
mange." 

Synonyms. — Capillorum  defluvium;  Athrix  depihs; 
Phalacrotes;  Depilatio;  Trichosis  athrix;  Gangraena 
alopecia  ;  Atrichia  ;  Defluvium,  seu  Lapsus  seu  Fluxus 
pilorum  ;  Lipsotrichia;  Vulpis  morbus;  Pelada;  Oligo- 
trichia ;  Calvities  ;  Psilosis;  Trichorrhoea  ;  Ophiasis  ; 
Calvitie  (Fr.);  Kahlheit,  Fuchsraude  (Ger.);  Calvezza 
(It.);  Baldness  (Eng.) 

Definition. — An  abnormal  loss  of  hair,  arising  from 
any  cause,  which  usually  affects  the  scalp,  but  may  in- 
vade any  portion  of  the  body. 

Varieties. — 1.  Alopecia  adnata,  or  congenital  bald- 
ness. The  form  occurring  in  infants  born  either  totally 
or  partially  without  hair.  2.  Alopecia  senilis.  The 
absolute  or  relative  baldness  of  old  age.  3.  Alopecia 
prematura,  seu  presenihs.  Baldness  occurring  before 
the  time  when  the  hair  usually  falls,  on  account  of  ad- 
vancing years.  It  may  be  idiopathic  or  symptomatic. 
4.  Alopecia  areata,  in  which  the  hair  falls  out  in  circu- 
lar patches. 

The  older  writers  used  various  terms  to  denote 
the  different  phases  of  baldness.  These,  happily, 
have  faUen  into  disuse.  They  were  the  following: 
Madesis  or  Maderosis,  used  to  denote  a  thinning  of  the 
hair.  Phalacrosis,  to  denote  baldness  beginning  at 
the  forehead.     Ophiasis,  to  signify  baldness  occurring 


ALOPECIA.  81 

in  a  serpentine  line,  running  from  the  occiput  towards 
the  ears,  and  sometimes  towards  the  forehead.  Opis- 
thophalacrosis,  baldness  beginning  at  the  back  of  the 
head.  Hemiphalacrosis,  baldness  affecting  one  half  of 
the  head.  Anaphalantiasis,  used  to  designate  loss  of 
the  eyebrows,  and  sometimes  general  baldness.  OKgo- 
trichia,  to  denote  thinness  of  hair.  According  to 
FouRNiER,  alopecia  should  be  used  to  denote  the  process 
of  hair-fall,  and  calvities  the  completed  baldness. 

1.  Alopecia  Adnata. 

Symptoms. — This  is  the  atrichia  of  the  old  waiters. 
It  is  congenital  baldness,  as  the  name  indicates,  and  is 
either  partial  or  complete.  Most  infants  come  into  the 
world  with  a  good  equipment  of  hair.  In  rare  instances 
the  child  is  born  partially  bald,  and  more  rarely  com- 
pletely so.  Hairless  races  have  been  reported.  One 
of  these  is  said  to  exist  in  Australia.     Hill  (157). 

Etiology  and  Pathology. — The  disease  is  due  to 
arrested  development  of  the  piliary  system;  and  micro- 
scopical examination  of  sections  of  the  skin  in  inveter- 
ate cases,  shows  a  deficiency  of  hair-follicles.  In  a  case 
reported  by  Jones  and  Atkins  (ICO),  of  a  boy  who 
never  remembered  having  had  hair,  microscopical  ex- 
amination of  the  scalp  revealed  only  a  few  aborted 
hair-follicles,  forming  shallow  pits  in  the  epidermic 
layer  with  open  extremities  looking  downwards.  In  two 
cases  reported  by  Schede  (1T9)  in  1S72,  one  of  which 
was  a  boy  thirteen  years  old,  and  the  other  a  girl  six 
months  old,  brother  and  sister,  there  was  no  hair  what- 
ever on  the  body,  not  even  lanugo  hair.  Microscopical 
examination  of  a  section  from  the  boy's  scalp  showed 
large,  well-formed  sebaceous  glands,  opening  directly 
on  the  scalp.  In  the  neighborhood  of  some  of  these 
glands,  just  above  their  lower  extremity,  were  found 
a  great  mnnber  of ''atheromas"  separated  from  the 


82  DISEASES  OF  THE   HAIR  AND  SCALP. 


glands  by  connective  tissue,  and  apparently  developed 
in  a  species  of  short  tubes,  which  in  structure  corre- 
sponded with  that  of  the  outer  root-sheath,  and  were 
no  doubt  the  beginnings  of  the  rudimentary  hairs. 
Luce  (166),  in  1879,  reported  a  case  in  which  the  hair 
'  did  not  grow  until  the  sixth  year,  and  in  which  the 
appearances  of  keratosis  pilaris  were  present.  Hutch- 
inson (158),  in  1886,  reported  a  case  of  congenital  ab- 
sence of  hair  in  a  boy  three  and  a  half  years  old,  the 
son  of  a  woman  who  had  been  almost  wholly  bald  from 
alopecia  areata  since  she  was  six  years  old.  In  this 
case  there  was  a  withered  condition  of  the  whole  in- 
tegument,  and  an  absence  of  nipples.  A  somewhat 
similar  case  is  reported  by  De  Mol^nes  (115  ap.).  The 
mother  had  had  alopecia  areata  some  years  before 
giving  birth  to  the  child  whose  case  is  reported.  At 
birth  there  was  a  scarcely  perceptible  down  upon  the 
scalp,  no  eyebrows,  and  hardly  visible  eyelashes.  At 
five  months  the  eyelashes  fell  out  and  the  scalp  be- 
came white  and  smooth.  There  was  no  keratosis  pi- 
laris. Teeth  and  nails  were  normal.  Under  stimu- 
lating treatment  during  three  years  the  hair  grew  in, 
excepting  on  a  small  place  behind  the  left  ear.  In 
some  families  there  is  an  hereditary  predisposition  to 
congenital  alopecia. 

Prognosis. — The  prognosis  is  usually  good.  The  hair 
in  most  cases  will  grow  in  course  of  time,  although  it 
may  not  be  as  abundant  as  it  should  be.  According  to 
MiCHELSON  (171),  when  congenital  alopecia  takes  the 
form  of  circumscribed  patches,  the  prognosis  is  bad. 
Delayed  dentition  and  diseased  nails  will  often  be  noted 
in  children  affected  with  this  disorder. 

Treatment.— As  to  treatment,  the  disease  usually 
requires  none,  as  it  generally  remedies  itself.  If  it  is 
very  disfiguring,  or  the  parents  require  something  to 
be  done,  stimulating  remedies  may  be  used,  as  in  alo- 


ALOPECIA.  83 

pecia  areata.  If  there  is  keratosis  pilaris,  the  free  use 
of  soap  frictions  every  day,  followed  by  inunctions  with 
oil,  will  serve  to  remove  the  epidermis  which  clogs  up 
the  hair-foUicles,  and  will  thus  give  the  hemmed-in 
hair  a  chance  to  grow. 

2.  Alopecia  Senilis. 

Symptoms.— This  form  of  baldness  is  that  which  oc- 
curs in  old  age.  It  is  often  preceded,  accompanied,  or 
soon  followed  by  other  signs  of  advancing  years,  such 
as  graying  of  the  hair,  fall  or  decay  of  the  teeth,  and 
diminution  in  keenness  of  the  sight.  The  hair  usually 
first  becomes  gi'ay,  loses  its  lustre  and  suppleness,  and 
then  falls  out  either  slowly  or  rapidly.  At  first  there 
may  be  only  a  general  thinning  of  the  part  about  to 
become  bald,  but  at  last  absolute  baldness  sets  in.  The 
fall  of  the  hair  usually  begins  at  the  vertex,  and  it  is 
not  uncommon  to  see  this  region  alone  affected  for 
some  time,  giving  the  appearance  of  the  tonsure.  It 
may  begin  at  the  anterior  superior  part  of  the  skull. 
Generally  the  course  of  the  disorder  is  from  behind  for- 
wards, or  from  before  backwards,  but  the  whole  top  of 
the  head  may  be  affected  at  once.  In  most  cases  the 
lateral  and  posterior  parts  of  the  skuU  are  spared,  and 
the  bald  patch  is  bounded  on  either  side  and  behind,  by 
a  semi-circle  of  hair,  running  along  the  temples  to  the 
neck.  It  is  always  symmetrical.  Neumann  (27)  draws 
attention  to  the  fact  that  both  in  senile  and  premature 
alopecia,  the  region  commonly  affected  corresponds 
quite  nearly  to  that  supplied  by  both  supra-orbital 
nerves,  and  in  very  extended  cases  the  regions  supplied 
by  the  temporal  and  the  occipitalis  major  and  minor 
are  also  included.  A  certain  amount  of  seborrhoea  sicca 
is  sometimes  present.  The  scalp  appears  smooth, 
stretched,  shiny,  sometimes  oily,  and  thinned. 

Etiology. — This  form  of  baldness  is  but  one  expres- 


84  DISEASES   OF  THE   HAIR  AND   SCALP. 


1 


sion  of  that  general  lowering  of  nutrition,  incident  to 
advancing  years.  The  age  of  forty-five  is  that  usually 
chosen  to  designate  the  dividing  hne  between  man's 
fullest  development  and  commencing  decay,  and  it  is  at 
about  this  period  that  senile  baldness  begins.  Women 
are  far  less  often  bald  than  men.  Why  this  is  so  we 
do  not  certainly  know.  In  the  section  on  premature 
baldness,  some  reasons  for  their  exemption  will  be 
given.  Neither  canities  nor  seborrhoea  are  causes  of 
this  form  of  alopecia.  Kaposi  (19)  says  that  atrophy 
of  the  scalp  tissue  does  not  precede,  but  follows  it  after 
a  considerable  lapse  of  time. 

Pathology.— There  is  a  lessening  of  the  subcutane- 
ous fat,  and  an  atrophy  of  the  corium,  the  coimective- 
tissue  fibres  of  which  have  undergone,  in  part,  fatty, 
and  in  part,  colloid  degeneration.  The  sebaceous 
glands  are  in  some  places  shrunken  and  in  some  wid- 
ened; the  hair-follicles  are  filled  with  epithelial  scales, 
the  remains  of  the  root  sheath,  and  often  contain  a 
thin  hair.  In  many  foUicles  the  hair  papiUa  has  disap- 
peared. Kaposi  (19).  Pixcus  (71)  found  in  senile 
baldness  that  there  was  a  rapid  relative  increase  in  the 
shedding  of  the  ''  spitzen  "  hairs,  (that  is,  those  hairs 
which  have  not  been  cut\  and  a  marked  and  increasing 
diminution  in  the  diameter  of  the  long  hairs;  also  an 
absence  of  seborrhoea  sicca  in  most  cases,  and  a  well- 
marked  atrophy  of  the  scalp.  Like  in  other  senile 
changes,  so  here  the  retrograde  process  begins  in  the 
arterial  supply  to  the  scalp,  and  we  find  a  fibrous  endar- 
teritis narrowing  the  lumen  of  the  cutaneous  arteries, 
till  finally  the  capillary  circulation  about  the  hair- 
foUicles  is  obliterated. 

Prognosis. — The  loss  of  hair  is  permanent.  In  some 
rare  cases  the  hair  has  grown  again  in  old  age,  and  tliis 
has  been  attended  by  the  development  of  new  teeth. 

Treatment. — When  the  scalp  is  atrophied  and  bound 


ALOPECIA.  85 

down  to  the  skull,  the  hair-follicles  are  too  far  gone  for 
any  stimulation  to  affect  them,  and  our  best  endeavors 
to  restore  the  lost  hair  will  be  in  vain. 

3.  Alopecia  Prematura. 

There  are  two  main  varieties  of  premature  baldness; 
Alopecia  Prematura  Idiopathica,  and  Alopecia  Prema- 
tura Symptomatica. 

Alopecia  Prematura  Idiopathica. 

Symptoms.— Alopecia  prematura  idiopathica  is  that 
form  of  baldness  which  begins  at  any  time  before  mid- 
dle age,  and  arises  uninfluenced  by  any  antecedent  or 
concomitant,  local  or  general  disease.  Usually  the  hair 
does  not  begin  to  fall  before  the  age  of  twenty-five 
years,  and  it  is  apt  to  progress  slowly.  The  hairs  which 
first  fall  out,  are  replaced  by  those  of  less  vigorous 
growth,  and  these  in  their  turn  are  shed  to  make  way 
for  still  weaker  ones,  and  so  the  process  is  repeated 
until  complete  baldness  results.  In  its  general  course 
it  is  similar  to  the  senile  form.  Like  it,  it  is  symmet- 
rical, it  begins  most  often  upon  the  vertex,  forming 
the  tonsure,  it  progresses  slowly,  has  the  same  boun- 
daries which  it  does  not  go  beyond  except  in  extreme 
cases,  and  leaves  a  smooth,  shiny,  bound-down  scalp. 
It  often  begins  anteriorly  and  recedes  at  the  sides,  giv- 
ing that  wide  and  high  forehead  thought  to  be  indica- 
tive of  wisdom.  It  may  leave  for  a  long  time  a  little 
islet  over  the  middle  and  anterior  part  of  the  skull. 
Unlike  senile  baklness,  it  is  not  preceded  by  canities, 
or  any  other  senile  change.  In  some  cases  the  fall  of 
the  hair  will  be  rapid,  then  cease  for  a  time,  to  begin 
again  and  progress  steadily.  The  beard  in  all  forms  of 
baldness  is  affected  rarely,  a  luxuriant  beard  being 
very  often  associated  with  a  more  or  less  bald  head. 

Etiology. — The  disease  is  in  many  cases  hereditary, 


86  DISEASES   OF  THE   HAIR  AND   SCALP. 

it  being  not  uncommon  to  meet  ^vith  families  in  which 
the  fathers  and  sons  for  many  generations  lose  their 
hair  early  in  hfe.  Pin'CUS  (173)  says  this  is  due  to  a 
markedly  stretched  condition  of  the  aponeurosis  of  the 
occipito-frontalis  muscle,  which  becomes  hereditary  in 
certain  families.  According  to  him,  ^' there  are  but 
two  predisposing  causes  of  alopecia  prematm-a.  They 
are:  1.  Inheritance.  2.  A  chronic  eczema  or  impeti- 
ginous eruption  on  the  scalp,  in  the  years  preceding 
puberty.  The  latter  is  the  most  frequent,  and  is  often 
connected  with  symptoms  of  relative  or  absolute  debil- 
ity." It  is  very  prevalent  in  those  leading  sedentary 
hves,  especially  so  in  brain-workers.  Jamiesox  (10  ap.) 
would  explain  this  on  the  theory  that  the  nerves  sup- 
plying the  scalp  are  in  direct  connection  with  those 
supplying  the  pia  mater  and  dura  mater,  and  that  an 
irritable  condition  of  the  brain  due  to  cerebral  conges- 
tion would  reflexly  interfere  with  hair-growth.  The 
continuous  wearing  of  cajDS  or  of  close-fitting  unventi- 
lated  hats,  a  practice  very  common  in  this  country,  is 
assigned  as  a  cause.  Some  hatters  claim  that  accord- 
ing as  the  head  is  long  or  ^^dde,  the  baldness  commences 
on  the  forehead  or  crown.  F.  A.  King  (161)  says 
''baldness  of  the  vertex  is  due  to  compression,  by  stifit 
hats,  of  the  anterior  temporal  arteries  in  their  course 
over  the  frontal  protuberances  ;  of  the  posterior  tem- 
porals at  or  near  the  parietal  ridges  ;  and  of  the  occi- 
pital behind.  The  reason  why  baldness  occurs  in  dif- 
ferent places  in  different  individuals  is  probably  due 
to  differences  in  the  shape  of  the  head.  The  httle  tuft 
of  hair  often  observed  on  top  of  the  forehead,  is  nour- 
ished by  the  two  supra-orbital  arteries,  which  escape 
pressure,  by  passing  over  the  forehead  in  the  slight 
concavities  between  the  frontal  eminences."  The  ex- 
istence of  the  islet  of  liair  in  front  is  probably  depen- 
dent upon  the  fact  that  it  lies  over  the  f rontahs  muscle, 


I 


ALOPECIA.  87 

and  is  not  upon  so  tense  a  substratum  as  the  other 
liair  of  the  vertex.  Lack  of  care  of  the  hair  is  an  ac- 
tive cause.  Ellinger  (150)  behoves  that  the  daily  use 
of  water  on  the  head  is  a  frequent  etiological  factor, 
and  has  found  this  the  case  in  eighty-five  per  cent,  of 
his  cases.  He  says  '^  the  form  due  to  water  begins  at 
the  forehead,  and  precedes  upward  and  to  the  sides  ; 
it  occurs  in  people  wlio  wear  the  hair  long,  and  is  due 
to  the  fact  that  the  water  at  the  point  of  exit  of  the 
hair  makes  an  emulsion  with  the  sebum  and  the 
scales  of  epidermis,  which,  hardening,  forms  a  plug 
to  the  hair-follicle,  causes  a  damming  up  of  the  sel)um 
in  the  follicle,  and  subsequent  atrophy  of  the  hair." 
In  an  article  upon  alopecia  by  Pohl  Pincus  (17Y)  it  is 
held  that  all  forms  of  the  disease  are  due  either  to 
primary  or  secondary  induration  of  the  scalp.  Some 
causes  of  primary  induration  are  said  by  him  to  be  the 
action  of  cold,  as  by  an  ice-bag,  gleet,  leucorrhoea, 
great  depression  of  spirits,  or  anxiety  of  mind,  which 
the  subject  struggles  against ;  while  in  those  cases  in 
which  the  subject  succumbs  entirely  to  his  depression, 
these  do  not  cause  baldness. 

It  has  been  noted  that  eunuchs  generally  have  hair 
neither  on  the  face  nor  pubes,  if  they  are  castrated  be- 
fore puberty  ;  and  if  castrated  after  puberty,  they  lose 
whatever  hair  they  had  on  those  regions.  Holder  (12^ 
ap.)  says  that  the  American  Indians  never  grow  bald. 
They  have  no  hair  on  their  bodies,  and  but  little  on 
the  pubes,  and  on  the  face  of  the  males.  Women  less 
often  become  bald  than  men.  The  reasons  given  for 
this  exemption,  are  that  they  do  not  wear  their  hats^  as 
much  as  men,  neither  are  their  hats  so  close  fitting, 
nor  made  of  so  impermeable  materials  as  are  men's 
hats;  that  they  give  more  attention  to  the  care  of  their 
hair  than  men  do;  that  they  carefully  avoid  wetting 
their  hair;  that  they  are  not  so  abundantly  covered 


88  DISEASES   OF  THE   HAIK  AND   SCALP. 

with  hail'  as  are  men,  and  therefore  do  not  suffer  so 
great  a  drain  upon  the  hair-forming  elements;  that  the 
hair  is  not  so  often  cut;  and  that  there  is  a  greater 
amount  of  subcutaneous  fat  in  women  than  in  men, 
and  this  is  preserved  longer  in  them.  PiNCUS  says 
''the  reason  why  they  suffer  less,  is  due  to  the  fact 
that  in  them  the  spaces  between  the  connective-tissue 
fibres,  in  the  deeper  and  middle  layers  of  the  scalp,  are 
much  larger  than  in  men,  the  skin  of  women  during 
their  life  preserving  more  of  the  characteristics  of  the 
skin  of  children.-'  In  an  analysis  of  one  hundred 
cases  of  baldness  appended  to  this  chapter,  the  remark- 
able fact  is  brought  out  that  there  is  a  tendency  for 
baldness  to  be  hereditary  in  the  line  of  sex.  Thus  in 
all  the  cases  in  women  there  was  a  distinct  history 
of  the  affection  occurring  on  the  maternal  side. 

That  the  beard  is  not  affected  is  because  the 
underlying  tissues  are  not  so  stretched,  as  is  the  case 
with  the  part  of  the  scalp  most  often  affected,  that 
is,  the  region  over  the  occipito-frontahs  aponeurosis. 
This  reason  would  also  hold  good  in  regard  to  the 
exemption  from  baldness  of  the  other  hairy  regions 
of  the  body,  and  of  the  parts  of  the  scalp  hair  which 
usually  do  not  fall  out. 

Pathology.— From  birth  up  to  the  age  of  twenty 
years  the  scalp  undergoes  a  continual  change  in  struc- 
ture, which  consists  in  increasing  thickening  and  ten- 
sion of  the  middle  layer  of  the  connective  tissue,  this 
being  most  marked  in  the  regions  most  commonly  af- 
fected by  alopecia,  namely,  over  the  aponeurosis  of  the 
occipito-frontalis  muscle,  and  least  marked  on  the 
temples.  In  both  alopecia  prematura  simplex  and  alo- 
pecia senilis  the  connective -tissue  which  binds  the  scalp 
to  the  underlying  parts,  suffers  stiU  further  changes. 
It  undergoes  a  narrowing  of  its  meshes  with  a  thick- 
ening of  its  fibres,  till  at  last  in  many  places  the  meshes 


ALOPECIA.  89 

disappear.  At  first  the  hair  loses  its  typical  length, 
but  not  thickness,  its  lustre  is  somewhat  diminished, 
and  both  the  quantity  and  quality  of  daily  fall  is  slightly 
increased,  more  short  hairs  being  shed  in  propoi*tion  to 
long  hairs  than  normally.  At  the  same  time  sebor- 
rhoea  sicca  generally  becomes  pronounced,  though  in 
about  ten  per  cent,  of  the  cases  it  is  wanting.  The 
thickening  of  the  subcutaneous  tissue  progresses  slow- 
ly, but  at  last  in  from  six  months  to  five  years,  the 
hair  begins  to  lose  in  thickness,  and  to  fall  more  rap- 
idly, and  baldness  sets  in.  The  diameter  of  the  hair  is 
in  direct  proportion  to  the  diameter  of  the  papilla;  and 
as  the  papilla  is  more  and  more  pressed  upon  and  re- 
duced in  size  by  the  increase  of  the  connective- tissue, 
the  diameter  of  the  hair  is  steadily  lessened.  At  first 
the  papillae  are  unaltered  in  constituence,  later  they  are 
obliterated,  and  then  no  more  hair  can  be  produced, 
and  the  part  is  bald.  If  the  process  of  indui-ation 
greatly  increases,  it  goes  beyond  the  aponeurosis,  and 
the  whole  head  becomes  quite  bald.     Pincus  (173). 

Prognosis. — If  the  disease  has  not  progressed  too 
far,  we  may  sometimes  stay  its  progress.  If  the  scalp 
is  so  tightly  adherent  to  the  subcutaneous  tissues  that 
it  does  not  readily  shde  upon  them,  we  can  not  hope 
to  better  the  condition.  A  well-marked  history  of 
heredity  renders  the  prognosis  unfavorable.  We  can 
best  watch  the  progress  of  the  case  by  having  the  pa- 
tient save  aU  the  hair  that  falls  from  his  head  for  three 
days,  putting  each  day's  faU  by  itself,  and  then  count- 
ing the  pointed  and  cut  hairs,  if  the  case  occur  in  a  man, 
or  the  hairs  over  and  under  six  inches,  if  the  case  occur 
in  a  woman.  If  the  uncut  hairs  of  a  man,  or  the  hairs 
mider  six  inches  of  a  woman,  exceed  one  quarter  of 
the  mass,  the  disease  is  progressive,  and  the  prognosis 
is  unfavorable;  if  under  one  quarter  the  prognosis  is 
better. 


90  DISEASES  OF  THE   HAIR  AND  SCALP. 

Tkeatmext. — 111  pei*sons  who  have  reason  to  expect 
early  hereditary  baldness,  prophylaxis  is  of  the  gi'eat- 
est  importance.  This  consists  in  close  attention  to  the 
hygiene  of  the  scalp,  and  of  the  general  health.  When 
the  disease  has  once  set  in,  it  must  be  combated  by 
means  of  stimnlating  apphcations,  as  in  symptomatic 
premature  baldness.  Shoemaker  (182  and  1  S3)  recom- 
mends that  to  persons  in  apparent  good  health,  who 
are  unconsciously  losing  their  hair,  either  mercury, 
tinctui'e  of  ignatia,  or  sulphurous  acid  should  be  ad- 
ministered. Either  the  bichloride  of  mercury  or  calo- 
mel is  given  by  him  for  a  short  period,  and  then  the 
tinctm*e  of  ignatia  in  ten-di'op  doses  three  times  a  day 
^ith  a  bitter  tonic,  and  thus  the  treatment  is  varied 
from  time  to  time,  according  to  the  patient's  condition. 
He  also  advises  the  use  of  the  oleate  of  u'on  locaUy  in 
these  cases.  The  use  of  jaborandi  or  pilocarpine  would 
seem  to  hold  out  some  hope  for  the  cui^e  of  this  affec- 
tion. In  IS 79  two  remarkable  cases  of  hair  grooving 
on  perfectly  bald  heads  were  reported  by  Geo.  Sch^iitz 
(ISO),  after  using  two  or  three  hypodermics  of  pilocar-^ 
pine  for  some  eye  disease.  In  one  case  the  man  was 
sixty  years  old  aud  quite  bald,  and  yet  a  vigorous 
growth  of  gray  and  black  hair  took  place  and  covered 
his  scalp.  In  the  other  case  the  man  w^as  thirty-four 
years  old,  vrith  a  small  bald  spot  upon  which  the  hair 
grew  so  as  to  cover  it.  Cottle  (52)  speaks  highly  of 
the  i)ower  of  either  of  the  following  lotions  to  stop  the 
fall  of  the  hair,  namely: 


Ac.  Acetici,  . 

3  ss.,  say      6 

Pulv.  boracis, 

.       3j.,     ''        1-50 

Glycerine,     . 

.       3iij.,   ''        4.50 

Spts.  vini. 

.         3SS.,     ''          6 

Aq.  rosae, 

adsviij.,^'     100 

M 

ALOPECIA.  91 

^Or,       Liq.  ammon.  acetat.,    .       lij.,  say    25 
;  Ammon.  carbonat.,       .       3ss.,   ^'  .75 

Glycerine,     .        .         .       3iij.,  ''        4.50 
:  Aq.  sambuci,         .  adSviij./'     100 

M 
PiNCUS  (175)  advises  in  acute  idiopathic  loss  of  hair 
the  avoidance  of  all  stimulation  of  the  scalp,  and  tem- 
perance in  eating,  drinking  and  mental  excitement. 
Where  the  fall  of  the  hair  is  progressive  and  chronic, 
and  while  it  is  still  merely  a  thinning  of  the  hair,  he 
directs  the  application  to  the  scalp,  for  two  to  five 
minutes  on  two  or  four  successive  days  of  each  week, 
of  a  lotion  composed  of: 

Bicarbonate  of  soda         .        .  2 

Distilled  water         ...       100 

M 

rubbing  in  one  to  two  tablespoonfuls  with  a  soft  hair- 
brush or  a  sponge.  On  the  first  or  second  day  of  the 
interval  between  the  applications,  some  oil  is  to  be 
rubbed  into  the  scalp.  This  treatment  is  to  be  con- 
tinued for  a  year,  and  then  if  the  disease  still  pro- 
gresses, more  powerful  remedies  are  to  be  used,  such 
as  will  be  spoken  of  under  the  treatment  of  alopecia 
furfuracea. 

Mayerhausen  (132  ap.)  reports  good  results  from 
the  use  of  static  electricity.  Mapother  (lol  ap.)  be- 
lieves that  as  the  hair  contains  sulphur,  silicon,  iron, 
and  manganese,  a  dietary  composed  largely  of  oat- 
meal and  rye  bread  will  promote  its  growth. 

Alopecia  Prematura  Symptomatica. 

Symptoms. — As  its  name  indicates  this  form  of  bald- 
ness occurs  as  a  consequence  of  some  other  local  or 


9^  DISEASES   OF   THE   HAIR  AND  SCALP. 


general  disease.  It  may  occur  at  any  time  before  old 
age  and  be  either  circumscribed  or  diffused,  depending 
upon  its  cause.  It  may  be  very  rapid,  as  after  fevers, 
the  hair  falling  out  by  handfuls,  in  which  case  it  is 
named  ''deiluvium  capillorum;  *'  or  it  may  be  very 
slow,  as  in  seborrhcea  sicca,  taking  years  to  produce 
complete  baldness.  Other  parts  of  the  piliary  system 
may  suffer  besides  the  scalp  hair,  as  in  trichophytosis, 
spyhiHs,  etc.  In  some  cases  aU  the  hair  of  the  body 
has  fallen  out  at  once,  as  after  sudden  nervous  shock. 
When  dependent  upon  non- symmetrical  diseases,  as 
variola,  pustular  diseases  in  general,  and  the  parasitic 
diseases,  the  baldness  will  be  asymmetrical. 

Its  main  varieties  are :  alopecia  f  urf  uracea  or  alopecia 
pityrodes;  alopecia  syphihtica;  defluvium  capillorum; 
and  a  class  comprising  the  non-symmetrical  cases  aris- 
ing from  local  lesions,  which  has  been  named  by 
T.  RoBixsoN  (75)  "alopecia  f ollicularis. "  The  most 
frequent  cause  of  alopecia  prematura  symptomatica,  is 
seborrhoea  sicca  or  pityriasis  simplex,  and  on  this  ac- 
count oar  first  attention  must  be  given  to 

Alopecia  Furfuracea.— In  this  there  is  always 
some  scaUng  of  the  scalp,  it  may  be  in  so  slight  a 
degree  as  to  constitute  the  commonly  called  "dan- 
druff," or  pityriasis  simplex;  or  the  process  may  be  so 
intense  as  to  produce  the  thick,  easily  friable,  grayish - 
white,  gi^easy  scales  of  seborrhoea  sicca.  This 
kind  of  baldness  is  met  with  in  aU  ages,  but  its  most 
serious  form  occurs  usually  between  the  twentieth 
and  thirtieth  year  of  life.  It  has  two  stages.  In  the 
first  stage,  simple  seborrhoea  sicca  or  pityriasis  is  pres- 
ent, and  the  hair  is  dry  and  falls  out  slightly.  The 
subject  notices  that  his  clothing,  especially  about  the 
shoulders,  is  covered  more  or  less  tliickly  with  gi-ayish 
epithehal  scales  mingled  with  sebaceous  matter,  and 
that  these  fiU  Ms  binish;  and  that  a  few  hairs  fall  out 


ALOPECIA.  93 

of  themselves  or  are  pulled  out  by  combing.  This 
stage  lasts  from  two  to  seven  years,  as  a  rule.  Now 
the  second  stage  begins,  when  to  the  seborrhoea  is 
added  a  rapid  fall  of  the  hair.  The  location  usually 
affected  is  the  same  as  in  alopecia  senilis,  the  top  of  the 
head,  from  vertex  to  forehead,  and  sometimes  over  the 
temples,  and  the  tuft  of  hair  just  over  the  forehead  is 
preserved  longest.  The  patient  does  not  become  bald 
at  once,  as  there  is  at  first  only  a  thinning  of  the  hair; 
then  a  diminution  in  the  length  and  diameter  of  the 
hair;  but  the  atrophy  continues  till  at  last  only  a  few 
lanugo  hairs  are  left,  which  in  their  turn  fall  out  and 
complete  baldness  results.  The  bald  scalp  appears 
white  or  of  rosy  hue;  is  often  stretched  over  the 
sutures,  though  frequently  easily  moved  over  the 
aponeurosis  of  the  occipito-frontalis  muscle;  and  it 
seems  thinned.  The  seborrhoea  keeps  pace  with  the 
intensity  of  the  disease,  until  the  hair  falls  out  markedly, 
when  it  lessens,  and  when  baldness  is  fully  established 
it  is  no  longer  present. 

Such  is  the  usual  course  of  the  disease.  In  infants 
seborrhoea  generally  gives  rise  to  thick  crusts,  which, 
being  removed,  bring  away  with  them  the  first  growth 
of  the  hair.  In  them  it  does  not  produce  permanent 
baldness.  In  women  the  region  affected  is  genei'ally 
that  occupied  by  the  part.  It  is  affirmed  that  they  are 
more  prone  to  seborrhoea  sicca  and  fall  of  the  hair  than 
men  are,  but  that  the  process  in  them  is  cnly  passing, 
and  the  fallen  hairs  are  soon  replaced.  Seborrhoea  sicca 
will  also  produce  a  general  thinning  of  all  the  hairy 
scalp,  but  this  is  usually  an  acute  and  temporary 
trouble. 

PiNCUS  (71)  says:  ^^  In  alopecia  pityrodes  the  definite 
proportion  between  the  hair  growth  and  fall  is  dis- 
turbed, the  latter  becoming  excessive.  The  longer  the 
seborrhoea  lasts  the  more  the  hair  gi*o^\i,li  will  fall 


94  DISEASES   OF  THE   HAIR  AXD  SCALP. 

behind.  When  the  proportion  of  short  hairs  to  the 
total  fall  is  as  1:8,  the  average  length  of  the  hair  being 
five  inches;  or  as  1:10,  the  average  length  of  the  hairs 
being  from  two  to  three  inches,  the  loss  is  abnormal." 
If  under  treatment  the  disease  is  checked,  and  the 
process  has  not  lasted  long  enough  to  cause  destruction 
of  the  hair  bulbs,  imj^rovement  vrWl  be  shown  by  a 
lessening  of  the  fall  of  the  hair,  and  by  and  by  a  growth 
of  lanugo  hairs  and  then  of  good  strong  colored  hairs. 

By  UxxA  (186)  a  method  is  proposed  for  proving  the 
improvement,  which  is  as  follows:  The  patient  is  di- 
rected to  gather  the  fallen  hairs  into  a  httle  bundle 
with  the  roots  all  looking  one  way,  so  that  the  condi- 
tion and  number  of  them  can  be  seen  at  a  glance.  So 
long  as  the  fall  is  rapid,  many  hairs  will  be  found  which 
have  just  passed  the  papilla  stage,  whose  knob-like 
roots  are  still  long,  and  often  have  a  drawn-out  epithe  - 
lial  projection.  The  less  the  fall  is  the  less  this  form  of 
root  wiU  be  found,  till  only  the  rounded  full  roots  are 
met  with,  which  shows  that  the  hairs  have  been  a  long 
time  in  the  ^^bed-hair"  stage." 

Alopecia  Syphilitica  next  claims  our  attention. 
It  occurs  most  often  early  in  the  disease  with  the  early 
specific  lesions,  but  may  occur  later,  with  the  tubercu- 
lar and  gummatous  lesions.  Syphilitic  exanthems  may 
be  present  on  the  scalp,  or  the  alopecia  may  be  the  only 
symptom  of  the  disease.  It  has  no  definite  time  of 
appearing,  coming  as  early  as  the  third  month,  or  as 
late  as  the  end  of  the  second  year.  When  it  is  the  result 
of  the  syphilitic  cachexia,  seborrhoea  is  often  present, 
and  there  is  a  general  thinning  of  the  hair  all  over  the 
head,  with  the  formation  of  irregular  patches  of  bald- 

*By  "  bed-hair  ''  is  meant  a  hair  which  has  been  cast  off  from 
its  papilla,  but  not  shed  from  the  follicle.  It  is  one  of  the  regular 
stages  in  the  life  of  every  hair,  and  shows  that  it  has  attained  its 
full  development. 


1 


ALOPECIA.  05 

ness  which  do  not  tend  to  form  circles.  In  the  patches 
we  often  find  tufts  of  long  hair,  and  the  head  has  a 
peculiar  ragged  look,  as  if  it  had  been  badly  cut  with 
dull  shears,  which  is  quite  characteristic.  In  some 
cases  the  middle  region  of  the  scalp  is  alone  affected. 
When  it  is  due  to  a  pustular  or  ulcerating  lesion  the 
baldness  is  localized  at  the  seat  of  the  lesion,  and  cica- 
tricial tissue  not  infrequently  takes  the  place  of  the 
normal  scalp  tissue. 

Other  regions  besides  the  scalp  may  be  affected,  but 
always  at  the  same  time  with  the  scalp.  The  broken 
arch  of  the  eyebrows  is  characteristic  and  is  most  often 
seen  in  women.  Alopecia  of  the  eyelashes  is  less  fre- 
quent. The  hair  of  the  pubes  is  quite  frequently  at- 
tacked; specially,  according  to  Fournier  (152),  is  this 
the  case  in  women. 

Usually  there  are  no  subjective  symptoms,  and  the 
fall  is  more  rapid  than  in  other  forms  of  alopecia.  It 
comes  in  both  benign  and  malignant  cases,  more  often 
in  the  latter.  Some  authorities  say  that  it  is  not  so 
common  as  it  used  to  be  in  former  times  when  it  was 
the  custom  to  salivate  the  patients,  and  hence  it  is  in- 
ferred that  it  is  due  to  the  administration  of  mercury. 
While  we  know  that  alopecia  is  one  manifestation  of 
chronic  mercurial  poisoning,  yet  as  alopecia  occurs  in 
syphilitic  cases  in  which  no  mercury  has  been  used,  we 
can  feel  assured  that  syphilis  of  itself  is  a  sufficient 
cause  of  the  baldness. 

DEFLUvroM  Capillorum  is  the  form  of  baldness 
which  follows  acute  diseases,  especially  fevers,  or  oc- 
curs in  the  course  of  some  cachexia  such  as  mercuri- 
alism.  Usually  the  hair  does  not  fall  out  till  after  con- 
valescence has  set  in,  when  the  fall  will  be  very  rapid. 
It  is  more  apt  to  be  a  general  thinning,  attacking  all 
parts  of  the  scalp,  than  a  localized  baldness,  and  in  most 
cases  is  associat'i^d  with  seborrhoea.     As  a  rule  it  is 


96  DISEASES   OF   THE   HAIR   AND  SCALP. 

not  very  intense,  and  rarely  produces  absolute  baldness. 
At  times,  however,  the  hair  of  the  whole  body  ^ill  faU 
with  gi'eat  rapidity  so  that  the  disease  will  have  a 
strong  resemblance  to  alopecia  areata  mahgna. 

Alopecia  Follicularis. — The  appearance  presented 
by  this  form  will  vary  T^ith  the  cause.  When  due  to 
pustular  diseases,  as  impetigo,  the  patches  are  not  larger 
than  from  the  size  of  a  dollar  to  that  of  the  palm  and 
we  may  have  cicatrices.  A"\lien  due  to  some  diffuse 
inflammatory  disease,  as  erysipelas,  the  patches  are 
quite  large  and  irregular,  and  the  scalp  is  hyperaemic. 
When  due  to  favus  or  ringworm  the  hairs  are  altered  : 
in  the  former  case  they  are  lustreless,  dry,  brittle  and 
sometimes  split  longitudinally  ;  in  the  latter  they  ai> 
pear  as  if  gnawed  off  near  the  roots.  The  scalp,  too, 
is  altered  ;  in  fa^Tis  in  old  cases  it  is  more  or  less  atro- 
phied ;  in  ringworm  it  is  usually  covered  with  thick 
scales  forming  a  crust. 

Etiology. — Alopecia  prematura  symptomatica  has 
many  causes.  We  have  already  mentioned  seborrhoea 
sicca,  syphilis,  fevers,  impetigo,  erysipelas,  variola, 
and  parasitic  diseases.  Besides  these  may  be  mentioned, 
violent  shocks  to  the  nervous  system  and  mental  dis- 
tress; parturition. lupus  erythematosus,  psoriasis,  lichen 
ruber,  lichen  scrophulosorum,  lepra,  and  other  cachex- 
ia?. Sweating  of  the  head  will  cause  the  hair  to  fall. 
Removal  to  the  seashore  is  often  attended  by  increasec 
fall  of  the  hair.  Scarlatina  has  been  followed  by  per- 
manent baldness. 

Tlie  baldness  following  fevers,  and  with  syphihtic 
and  other  cachexia^,  is  due  in  most  cases  to  seborrhoea, 
but  may  be  purely  a  nutritive  trouble,  the  bulbs  being 
badly  nourished,  the  hair  becoming  loose  and  falling 
out.  This  view  is  suppoiiied  by  the  fact  that  the  hair 
does  not  fall  out  till  some  time  has  passed  since  the 
onset  of  the  fever,  and  2:rows  in  again  when  convales- 


ALOPECIA.  9Y 

cence  is  fully  established.  Giovannini  (121  ap.)  says 
that  the  baldness  of  syphilis  is  due  to  a  deep  folliculitis 
pilaris,  and  not  to  anaemia  or  atrophy.  The  baldness 
of  the  pustular  diseases,  such  as  variola  and  the  syphi- 
lides,  and  of  the  destructive  diseases,  such  as  lupus 
erythematosus,  is  due  to  the  destruction  of  the  hair- 
follicles.  The  baldness  which  is  found  to  follow  the  uce 
of  mercury,  excess  in  venery  and  intemperance,  is  due 
to  their  damaging  effect  upon  the  constitution  of  the 
patient.  Anything,  in  fact,  which  will  tend  to  impair 
the  full  vigor  of  a  man,  may  secondarily  contribute  to 
the  production  of  baldness,  especially  if  he  has  a  pre- 
disposition thereto.  This  it  may  do  by  its  effect  upon 
the  nutrition  of  the  hair,  or  more  commonly  through 
a  pityriasis  simplex  or  seborrhoea  sicca. 

Brocq  (111  ap.)  believes  that  many  cases  of  so-called 
alopecia  furfuracea  are  really  due  to  keratosis  pilaris, 
which  is  capable  of  destroying  the  hair-follicle  when  it 
is  attended  by  an  inflammation.  He  reports  the  case  of 
a  boy  with  small  patches  of  baldness  on  the  scalp  which 
appeared  sieved  and  showed  no  sign  of  lanugo  hairs. 
He  had  keratosis  pilaris  both  of  the  scalp  and  body. 

Lassar  and  Bishop  (163)  maintain  that  alopecia  fur- 
furacea is  contagious,  and  is  frequently  transmitted  by 
the  agency  of  barber's  brushes  and  combs.  Hence, 
they  state,  women  are  less  often  affected  than  men, 
because  they  are  not  so  much  exposed  to  infection  at 
the  hands  of  the  barber.  They  base  their  opinion  upon 
the  following  experiments:  They  took  a  twenty-five 
years  old  student,  of  sound  health  and  without  nervous 
tendency,  belonging  to  a  family  in  which  baldness  was 
uncommon.  This  student  had  been  growing  bald  for 
five  or  six  years.  The  baldness  was  absolute  only  over 
the  forehead,  but  the  hair  was  very  thin  from  there  to 
the  vertex,  the  sides  being  spared.  In  the  thin  part,  the 
hair  was  short  and  dry.     The  hair  of  the  neighboring 


OS  DISEASES   OF  THE   HAIR  AND  SCALP. 

parts  was  somewhat  lustreless  and  brittle,  coming  out 
easily  on  slight  traction.  There  was  only  a  slight, 
dusty  pityiiasis.  There  was  a  httle  itching,  and  the 
scalp  showed  some  excoriated  places  made  by  the 
patient's  nails  in  scratching.  The  itching  had  been 
present  for  some  years,  especially  when  he  was  work- 
ing or  reading.  The  hair  loss  had  been  gradual  till  the 
preceding  summer,  when  during  a  foot  tour  in  hot 
weather,  it  had  increased  more  rapidly.  From  this 
student's  shed  hair  and  scales,  a  pomade  was  made  by 
chox)ping  them  up  fine  and  mixing  them  with  vasehne. 
This  pomade  was  spread  over  the  back  of  a  guinea  pig 
and  of  a  rabbit,  and  the  animals  watched  while  kept 
in  the  best  hygienic  surroundings.  In  the  course  of 
three  weeks  there  formed  upon  the  backs  of  these  ani- 
mals patches  of  absolute  baldness  as  large  as  the  palm 
of  the  hand;  other  places  showed  marked  thimiing  of 
the  hair,  wliich  came  out  \\ith  tlie  sUghtest  traction; 
and  there  was  present  a  mealy  desquamation  similar  to 
that  on  the  student's  head.  To  control  this  experiment, 
it  was  repeated  on  another  guinea  pig  and  rabbit,  and 
upon  yet  a  third  rabbit;  in  these  cases  the  hair  being 
taken  from  No.  1  and  No.  2  respectively.  The  results 
were  in  all  cases  similar,  only  attained  more  rapidly. 
In  all  the  cases  the  baldness  preceded  from  the  infected 
into  the  sound  parts. 

It  must  not  be  thought  that  every  case  of  seborrhoea 
of  the  scalp  will  be  followed  by  loss  of  hair.  In  those 
who  inherit  naturally  vigorous  hair  this  may  not  oc- 
cur. It  is  when  there  is  an  inherited  tendency  to  loss 
of  hair  that  seborrhoea  will  quite  surely  cause  alopecia. 

In  ISTtt,  Malassez  (169)  and  Chincholle  (lJr2)  de- 
scribed a  vegetable  parasite  as  present  in  pityriasis  sim- 
plex, oval  in  shape,  which  disappeared  ^-ith  the  disap- 
pearance of  the  pityriasis.  Malassez  described  it  as 
*^  constituted  of  spores  without  tubes  of  myceHum, 


ALOPECIA.  99 

generally  oval  in  shape,  seldom  spherical,  and  very 
small.  It  inhabits  the  corneous  layer  of  the  skin,  and 
penetrates  the  follicles,  but  does  not  reach  the  orifice 
of  the  sebaceous  gland.  It  is  generally  very  abundant, 
and  is  the  cause  of  the  disease."  Recent  investiga- 
tions by  BizzozEKO  tend  to  shov^  that  these  spores  are 
found  generally  upon  the  normal  human  skin  (003). 
Unna  (141  ap.)  has  found  cocci  in  seborrhoeal  eczema 
of  the  scalp  from  which  he  has  made  cultivations.  He 
has  produced  in  a  rabbit  progressive  falling  of  the  hair 
with  pityriasis  by  inoculations  with  these  cultiva- 
tions. 

Much  that  has  been  given  in  the  etiology  of  idiopa- 
thic alopecia  prematura,  especially  in  regard  to  the  use 
of  water  on  the  head,  the  wearing  of  hats,  etc.,  could 
be  repeated  here,  since  they  tend  to  produce  pityriasis 
and  in  that  way  alopecia  furfuracea. 

Pathology. — As  we  have  learned,  the  majority  of 
the  cases  of  premature  symptomatic  baldness  that  are 
not  due  to  destructive  diseases  are  due  to  seborrhoea  or 
pityriasis  simplex.  We  will,  therefore,  give  our  atten- 
tion first  to  the  pathology  of  alopecia  furfuracea  seu 
pityrodes.  In  seborrhoea  sicca  there  is  a  too  hasty  cast- 
ing off  of  the  hning  ceUs  of  the  sebaceous  glands,  and 
as  these  are  continuous  with  those  lining  the  hair- folli- 
cle, it  is  probable  that  a  like  increase  in  the  shedding  of 
the  cells  of  the  hair-foUicle  takes  place.  This  nuist  be 
followed  by  interference  with  the  nutrition,  and  loosen- 
ing and  falling  of  the  hair.  If  the  process  can  be 
stopped  before  the  papiUae  become  atrophied  the  hair 
will  grow  again.  If  the  process  has  continued  un- 
checked for  from  six  to  ten  years,  the  papilk^  will 
probably  be  destroyed,  and  the  baldness  will  be  perma- 
nent. The  normal  life  of  a  hair  is  one  year  or  more;  it 
may  be  three  months  or  less.  The  shorter  time  the  hair 
lives,  the  shorter  and  thinner  it  will  be.     In  this  form 


100  DISEASES   OF  THE   HAIR   AND   SCALP. 

of  alopecia,  the  quantitative  propoi-tiou  of  the  short 
("spitzen-')  hairs  to  the  total  shed  hail's  is  increased 
markedly  ^Wthout  the  absolute  daily  hair  loss  being 
as  markedly  increased.  The  characteristic  of  the  first 
stage  is  that  hairs  suffer  an  increasing  diminution  in 
their  normal  leng-th,  the  later  gro^\i:hs  often  having  a 
markedly  shorter  length  of  hfe  than  those  that  have 
gone  before.  The  lessening  of  the  length  of  growth 
is  due  to  a  shortening  of  the  typical  life.  The  charac- 
teristic of  the  second  stage  is  a  reduction  in  the  diame- 
ter of  the  hair.  The  hairs  occui*  in  bundles  of  from 
three  to  five  together.  The  life,  length,  and  diameter 
of  the  bans  in  the  same  group  vary  considerably,  and 
they  do  not  all  die  at  the  same  time.  In  fever  pro- 
cesses, however,  a  whole  group  often  falls  at  once. 
PiNCUS,  (173). 

Malassez  (170),  a  supporter  of  the  parasitic  theory  of 
alopecia  pityi'odes,  explains  its  occurrence  as  follows: 
The  parasite  causes  an  irritation  of  the  foUiculai- walls, 
followed  by  their  hypertrophy.  This  h}'pertrophy 
closes  the  cavity  of  the  follicle,  causes  a  fibrous  trans- 
formation of  the  follicle,  and  final  fall  of  the  hair. 

In  defluvium  capillorum,  when  it  does  not  depend 
upon  a  pityriasis  or  a  seborrhoea,  we  may  find  an  ex- 
planation for  the  sudden  faU  of  the  hair  in  the  ar- 
rangement of  the  blood  supply  as  suggested  by  Unna, 
(82  a)  and  given  on  .page  38  of  this  book. 

Prognosis.  —  This  will  vary  with  the  cause.  The 
])rognosis  of  alopecia  furfuracea  is  good  if  proper 
treatment  is  begun  while  tlie  hair  is  only  thinned,  and 
the  scalp  is  not  actually  bald.  Then  we  have  fail* 
ground  for  hope  if  there  is  no  predisposition  to  the 
disease  and  lanugo  hairs  are  present.  When  the  scalp 
is  atrophied  and  bound  down  to  the  skuU,  the  prospects 
are  bad.  Pincus  says  that  the  nearer  to  pobertj  the 
disease  begins,  the  more  rayiil  wiD  be  its  com'se. 


ALOPECIA.  101 

The  prognosis  of  defluvium  capillorum  is  usually 
good.  This  is  especially  the  case  after  fevers  and  par- 
turition. It  may  be  generally  stated  that  the  prog- 
nosis of  alopecia,  due  to  local  disease  of  the  scalp,  is  the 
more  favorable  the  more  superficial  the  disease  is  which 
causes  it;  thus,  it  is  good  after  eczema  and  erysipelas, 
bad  after  lupus  and  the  ulcerative  diseases,  in  which 
thei-e  is  destruction  of  tissue  and  production  of  cica- 
trices. 

Before  beginning  the  treatment  of  any  case  we  must 
explain  to  the  patient  that  rapid  results  cannot  be 
expected,  and  success  wiU  depend  largely  upon  the 
care  with  which  he  carries  out  directions,  and  upon 
his  perseverance.  At  least  one  year  of  treatment  must 
be  stipulated  for.  I  have  found  that  women  will  give 
much  more  attention  to  the  physician's  directions  than 
men,  and  this  is  probably  one  reason  why  results  are 
more  satisfactory  with  them. 

Diagnosis. — Alopecia  prematura  symptomatica  is 
diagnosed  from  the  other  forms  of  alopecia  by,  usually, 
the  presence  of  a  seborrhoea  or  SDme  local  disease,  by 
its  running  a  more  irregular  course,  and  by  a  less 
marked  atrophy  of  the  scalp.  From  senile  alopecia 
the  absence  of  other  senile  changes  will  distinguish  it; 
and  the  lack  of  smooth,  circular,  oval,  or  serpiginous 
patches  serves  to  differentiate  it  from  alopecia  areata. 

Alopecia  syphilitica  is  diagnosed  by  its  sudden  inva- 
sion; by  its  non -inflammatory  and  non-pruritic  char- 
acter; by  the  ragged  appearance  it  gives  to  the  hair 
with  its  irregular  patches  of  baldness;  sometimes  by 
the  presence  of  syphilides  on  the  scalp  or  elsewhere  on 
the  body;  and  by  the  history  of  infection. 

Treatment. — Prophylaxis. — It  should  be  especially 
urged  upon  those  predisposed  to  baldness  that,  by 
proper  care  of  the  hair  and  scalp,  much  may  be  done 
to  prevent  the  early  fall  of  the  hair.     The  pi-ophylactic 


102  DISEASES    OF  THE    IIAIK    AXJ)    SCALP. 

treatment  consists  in  brushing  and  combing  the  hair, 
washing  the  scalp,  the  avoidance  of  the  abuse  of  local 
apphcations,  and  the  attention  to  certain  hygienic 
laws;  matters  which  have  already  been  fully  consid- 
ered in  the  chapter  on  hygiene. 

Curative  Treatment. — When  due  to  seborrhoea  or 
pityriasis,  the  first  thing  to  be  done  is  to  remove  all 
crusts  and  scales.  This  is  accomplished  by  the  use  of 
soap  and  water  when  there  is  only  scahness,  and  for 
our  soap,  the  tincture  of  green  soap,  composed  of  equal 
parts  of  sapo  ^iridis  and  alcohol  or  cologne  water,  is 
the  best.  This  acts  both  as  a  cleanser  and  a  stimulant. 
The  soap  should  always  be  washed  out  mth  a  copious 
stream  of  water,  using  it  hot  and  cold  alternately, 
when  convenient.  If  there  is  a  tendency  to  dryness 
of  the  hair,  as  there  generally  is  in  these  cases,  after 
diying  the  scalp  and  hair  carefully,  a  little  oil  or  vase- 
line should  be  rubbed  mto  the  scalp.  Or  instead  of 
the  soap,  if  the  scalp  is  very  irritable,  we  may  use  a 
shampoo  of  eggs — the  yolks  of  three  eggs  being  beaten 
up  in  one  pint  of  lime  water,  to  which  half  an  ounce 
of  cologne  water  may  be  added.  Rub  this  thoroughly 
into  the  head  after  carefully  brushing  it,  and  wash  out 
the  same  as  after  using  soap.  Where  there  are  thick 
crusts  this  will  not  suffice,  and  we  must  use  oil.  Let 
the  patient  saturate  the  head  with  sweet  almond  oil, 
put  on  an  oiled  silk  cap,  and  keep  it  on  aU  night.  The 
next  morning  wash  the  head  with  borax  and  water. 
This  is  to  be  repeated  every  night  until  the  head  is 
clean,  and  afterwards  an  occasional  wash  with  the 
tincture  of  green  soap  or  borax  and  water  will  suffice 
for  cleanliness.  Sopping  on  alcohol,  with  or  without 
two  to  five  per  cent  of  tincture  of  benzoin,  will  hasten 
the  drying  of  the  hair  aft-er  washing. 

Cases  of  alopecia  furfuracea  as  a  rule  need  stimula- 
tion, and  to  this  end  a  multitude  of  hair  tonics  have 


ALOPECIA.  103 

been  used,  such  as  carbolic  acid;  tincture  of  cantharides; 
tincture  of  cinchona;  tincture  of  nux  vomica;  tincture  of 
capsicum;  ammonia;  chloral;  corrosive  sublimate;  and 
the  like.  The  good  these  substances  do  is  by  their 
stimulating  properties,  and  no  one  of  them  can  boast  of 
any  specific  action.  They  must  be  made  strong  enough 
to  cause  the  scalp  to  glow,  but  not  to  irritate  it  to  the 
point  of  inflammation. 

Carbolic  acid  may  be  used  as  strong  as  two  per 
cent,  in  alcohol:  tincture  of  capsicum,  and  tincture  of 
cantharides  of  the  strength  of  3  j — iij  (4.0  to  12.0)  to  3  j 
(30.0):  chloral,  up  to  3  j  (4.0)  to  3  j  (30.0);  tincture  of  nux 
vomica  say  3j  (4.0)  to  sj  (30.0);  corrosive  sublimate 
gr.  i — iij  to  3  j ;  aq.  amnion,  fort,  may  be  used  in  some 
cases  pure,  but  better  diluted  to  the  point  of  tolera- 
tion. 

Or  ointments  containing  these  or  other  substances 
may  be  used.     A  good  one  is 

Hydrarg.  amnion.,  .  .  gr.  Ix.,  say  9 
Hydrarg.  chlor.  niitis,  .  gr.  Ixxx.,  ^^  18 
Petrolati,    .        .        .        ad  3  j.,  ''100 

M. 

Sulphur  also  acts  well,  in  the  strength  of  3  ss — ij, 
to  1  j.     Unna  (180)  recommends  : 

Sulph.  precip.,    .....      10 

Adeps, 100 

M. 
rubbed  in  every  evening,  at  first  from  before  backward, 
and  then  around  and  around.  Every  three  or  four  days 
the  head  is  to  be  washed.  So  soon  as  desquamation 
lessens,  rub  in  every  second  evening,  and  so  gradually 
decrease.  If  the  scalp  is  irritated,  he  substitutes  uiigt. 
zinci  oxid.  for  the  lard  in  the  above  prescription.  Sul- 
phur has  proved  itself  of  value  in  my  hands,  and  it  is 
the  remedy  in  which  I  have  most  confidence.  The 
disagreeableness  of  using  ointments  upon  the  scalp  is 


104  DISEASES   OF   THE   HAIR   AND   SCALP. 

much  lessened  by  using  ar  very  little  of  the  ointment, 
and  rubbing  it,  or  having  it  rubbed,  thoroughly  into 
the  scalp,  and  not  smeared  on  the  hair.  Thanks  to 
the  kindness  of  Messrs.  Daggett  &  Ramsdell,  of  this 
city,  I  have  been  able  to  use  for  the  past  two  years  a 
most  elegant  Snijyhiir  Cream  composed  of  : 

5  Cerae  albce,    .         .        .        .        .      3vij. 
01.  petrolati,         .        .        .        .      3  v. 

Aq.  rosa?, !  ijss. 

Sodae  biborat.,      ....     gr.  30 

Sulphur, 3  vij. 

This  is  not  very  greasy,  and  it  acts  efficiently. 

PiNCUS  (17o)  ad^^ses  in  the  first  stage,  when  the  scal- 
ing is  pronounced  and  the  hair  begins  to  fall,  a  solution 
of  bicarbonate  of  soda  strong  enough  to  redden  the 
patient's  forehead  after  rubbing  it  a  few  minutes.  This 
is  to  be  nibbed  thoroughly  into  the  scalp,  a  compress 
to  be  applied  over  it,  and  an  oil  silk  cap  to  be  worn  all 
night.  One  objection  to  tliis  is  that  it  stains  the  hair 
a  dirty  reddish  brown.  In  the  second  stage,  when  the 
hair  fall  is  pronounced,  1>  Tanin  gr.lxxx  (6.00);  ungt. 
rosae  33  (30.0)  is  to  be  rubbed  in  every  night,  and  the 
head  cleansed  two  or  three  times  a  week.  A  lotion  of 
01.  sabiuce  gr.v—xxx(0. 30—2.0)  to  alcohol  3  j  (30.0)  M. 
apphed  every  night  is  better,  as  it  may  be  interrupted 
for  two  or  three  weeks  at  a  time,  while  the  tamiin  cannot 
be  stopped  more  than  six  days.  A  hood  is  to  be  worn 
during  the  night  with  either  of  these.  The  ol.  sabinae 
often  causes  headache,  nausea,  vertigo,  and  sleepless- 
ness, which  is  an  objection  to  its  use. 

PoHL  PiNcus  (177)  advises  the  use  of  a  lotion  compos- 
ed as  follows: 

Ac.  lactic,    .         .         .         .         0.5  to      1.0 
Ac.  boracic,  .         .         .         2.0  to      5.0 

Aq.  destilat,         .         .         .  220. 

Spts.vini  rect.      .        .        .        30  to    40. 
M. 


ALOPECIA.  105 

Two  to  three  teaspooiif uls  of  this  are  to  be  rubbed  into 
the  head  once  or  twice  daily  for  three  or  four  minutes. 
Or  an  ointment  may  be  substituted  composed  as  fol- 
lows: 

Ac.  lactic, 1  to    3 

Ac.  boracic,  .        .        .        .     8  ^'  12 

Adeps,  vel 

Vaseline, 100 

01.  bergamii,        ....  q.s. 

M. 

Two  to  four  pea-sized  masses  of  this  are  to  be  rubbed 
into  the  bald  places  once  or  twice  daily  for  three  min- 
utes. After  using  either  of  these  for  two  or  three 
weeks,  he  makes  a  pause  of  a  few  days,  and  then  for 
one  week  uses  : 

Sodii  carbonat.,    .         .         .         .     3  to     8 

Adeps,  vel 

Petrolati, 100 

01.  bergamii,        .         .         .         .  q.s. 

M. 
in  the  same  manner  as  the  previous  ointment,  and  so 
alternates  his  remedies  for  a  year. 

Lassar  (163)  managed  the  case  cited  under  etiology 
upon  the  antiparasitic  plan,  with  the  result  of  causing 
a  growth  of  strong  new  hair  by  the  end  of  the  eighth 
week.  The  patient's  head  was  daily  washed  with  a 
sti'ong  tar  soap  which  gave  a  good  lather,  which  was 
rubbed  i]i  for  fifteen  minutes.  The  soap  was  then 
washed  out  with  water,  at  first  warm,  then  gradually 
cooler,  at  last  cold.  Then  a  wash  composed  of  equal 
parts  of  a  solution  of  corrosive  subhmate  (1.  to  300.0), 
spts.  cologne  and  glycerine,  was  thoroughly  applied. 
The  head  was  then  dried  and  a  napthol  solution  (nap- 
thol.  0.5;  spts.  dilut.  70.0;  aq.  destil.  30.0)  was  rubbed 
in.     Finally  a  one  and  a  half  per  cent,  solution  of 


106  DISEASES   OF  THE   HAIR   AND  SCALP. 

carbolized  oil  was  slowly  poured  over  the  head.  In 
1S88  (130  ap.)  he  gives  as  a  substitute  for  this  trouble- 
some treatment  the  following  : 

I^  Carbolic  acid, 1.5 

Sublimed  sulphur,     ....     6 
Horse-neck  fat,  ...  100 

M. 
He  also  commends  oil  of  turpentine  with  equal  parts 
of  oil  or  alcohol. 

Paschkiss  (131  ap.)  believes  that  where  there  is  a  good 
deal  of  seborrhoea  oily  applications  should  be  avoided^ 
and  the  scalp  should  be  washed  daily  with  tincture 
of  green  soap  ;  or  a  soap  composed  of  castile  soap 
40  to  50  grains,  potash  or  soda  10  grains,  and  water 
half  a  pint.  The  suds  should  be  left  on  from  ten  min- 
utes to  several  hours.  In  women  this  is  impracticable, 
and  we  must  substitute  for  the  soap  a  two  to  five  per 
cent,  solution  of  soda.  If  this  fades  the  hair  the  color 
will  be  restored  by  the  use  of  oil.  We  may  use  benzol 
with  equal  parts  of  alcohol.  If  these  means  do  not 
cure,  resort  may  be  had  to  naphthol,  resorcin,  or  ich- 
thyol.  After  the  seborrhoea  is  somewhat  lessened,  we 
should  apply  to  the  scalp  every  day  either 

1^  Quiniuce  sulphat.,      .         .         .         1.50 
Spts.  vini  gallici,        ...       65 
Aquae  cologn.,  ...        ad  100 
M.  or 

B  Tannin,      .  .         .         .         .     1  to  5 

Alcohol,  q.  s.  ad  solut., 
01.  amygdalae  dulc,  .        .    40 

M. 
Shoemaker  (31  ap.)  recommends  equal  parts  of  oleate 
of  iron  and  oil  of  ergot  or  any  other  oil  \  also  sopping 
on  the  tincture  or  fluid  extract  of  soap  bark. 

Heitzmanx  (156)  recommends  in  these  cases  the  use 
of  crude  oleum  i-usci  in  the  proportion  of  10  per  cent. 


ALOPECIA.  107 

to  20  per  cent,  in  an  ointment  of  vaseline  and  paraffin, 
with  enough  fragrant  oil  to  cover  the  smell  of  the  tar. 
This  is  to  be  alternated  with  sulphur  and  white  pre- 
cipitate ointments.  He  claims  that  twenty-four  per 
cent,  of  two  hundred  cases  were  temporarily  benefited, 
and  in  a  small  percentage  the  improvement  was  last- 
ing. 

Ihle  (159)  recommends  the  use  of  resorcin  as  follows: 
Resorcin  pur,  ....  5 

01.  ricini, 45 

Spts.  vini 150 

BaLs.  peiiiv.  .        .        .         .  0.5 

M. 
This  is  to  be  rubbed  into  the  scalp  daily  with  a  piece  of 
flannel.     It  forms  an  agreeable  mixture  with  a  sliglit 
odor  of  alcohol.     This  drug,  as  well  as  tcthyol,  has  also 
been  highly  recommended  by  Unna. 

So  much  for  local  measures.  As  seborrhoea  is  an 
indication  of  lowered  vitality,  the  general  health  must 
be  cared  for,  and  tonics  given  when  indicated. 

In  syphilitic  alopacia  our  main  dependence  is  upon 
the  internal  treatment — mercury  or  iodide  of  potassium 
being  used  according  to  the  stage  of  the  disease.  Lo- 
cally, if  any  lesions  are  present,  we  may  use  a  lotion  of 
bichloride  of  mercury,  or  an  ointment  of  the  ammoni- 
ate  of  mercury.  Stimulating  remedies,  as  in  alopecia 
furfuracea,  may  be  used  with  advantage.  Defluvium 
capillorum  takes  care  of  itself  in  most  cases.  Its 
treatment,  when  needed,  is  that  of  alopecia  furfuracea. 
Alopecia  arising  from  local  diseases  needs  the  treat- 
ment applicable  to  the  special  disease  present,  which 
will  be  given  in  the  appropriate  chapters  of  this  work. 
In  pustular  diseases  affecting  the  scalp,  if  the  haii's  are 
early  extracted  before  the  foUicles  are  destroyed,  much 
will  be  accomplished  to  prevent  alopecia. 


108  DISEASES  OF  THE   HAIR  AND  SCALP. 

Loss  OF  Hair  :  A  Clinical  Study  of  its  Causes, 
Founded  on  One  Hundred  Cases. 

I  have  chosen  the  term  ''  loss  of  hair,"  rather  than 
baldness,  because  in  my  tables  I  have  placed  a  number 
of  cases  in  which  absolute  baldness  was  not  present, 
but  a  general  thinning  of  the  hair,  which  if  not  checked 
would  lead  to  baldness.  Cases  of  defluvium  capillorum 
coming  on  after  acute  illnesses  are  also  included. 

Of  the  100  cases,  65  occurred  in  men  and  35  in 
women. 

Of  these  the  nationality  was  :  Canada,  1 ;  Ireland,  1 ; 
Germany,  3  ;  United  States,  95. 

Condition  : 

Married 12  men,  16  women. 

Single 45    **      16      " 

Widowed 3      '* 

Not  recorded 8 

Occupation.     Of  the  men  : 

Architect,  1  Librarian,  1 

Bookbinder,  1  Lithographer,  1 

Brokers,  5  Lawyers,  5 

Clergymen,  2  Manufacturers,  2 

Clerks,  8  Mechanics,  2 

Dentist,  1  ISterchants,  2 

Electrician,  1  Physicians,  15 

Farmers,  2  Presser,  1 

Grocer,  1  Waiter,  1 

Lecturer,  1  None,  5 

Of  the  women ; 

Housewives,  16  Singer,  1 

Gloves,  1  None,  16 

Age  at  beginning : 

From  10  to  20  years 7  men  and  7  women 

••     20to30    "      44    "      "11      " 

"     30  to  40    " 12    "      *•  11      *' 

"     40to50     "      1     "      "3      ** 

Over  50  years 2      ** 


LOSS  OF  HAIR.  109 

The  greatest  number  of  cases  began  in  the  twenty- 
fifth  and  twenty-sixth  years,  viz.,  9  in  each  year.  The 
next  most  frequent  age  was  twenty-two,  with  8. 

The  baldness  or  loss  of  hair  took  the  form  of  a  gene- 
ral thinning  in , 6  men,  19  women. 

It  affected  the  crown  and  temples  in 13  " 

alone  in 32  "  10  " 

temples  in .  4  "  2  ** 

*'       and  tonsure  in 5  " 

tonsure  in    4  * '  2  " 

occiput  in 1  " 

parietal  region  in  1  "  1  " 

The  following  diseases  were  noted  as  complicating 

the  loss  of  hair  : 

Anaemia,  4  cases.  Malaria,  7  cases. 

Chancroid,  1  case.  Measles,  1  case. 

Chorea,  1  case.  Menopause,  1  case. 

Constipation,  1  case.  Metrorrhagia,  1  case. 

Dyspepsia,  11  cases.  Overtrainiug,  1  case. 

Dyspepsia  and  constipation,  5  cases.  Parturition,  3  cases. 
Endometritis  chronica,  1  case.  Peritonitis,  1  case. 

Gonorrhoea,  1  case.  Pneumonia,  2  cases. 

Gout,  1  case.  Spermatorrhoea,  1  case. 

Headache,  4  cases.  Sunstroke,  1  case. 

Influenza,  1  case.  Urethritis  chronica,  1  case. 

Uterine  fibroids,  1  case. 

The  cases  of  loss  of  hair  following  influenza,  measles, 
parturition,  pneumonia,  peritonitis,  and  sunstroke 
were  what  are  called  defluvium  capillorum,  and  came 
on  from  one  to  five  months  after  convalescence. 

The  scalp  and  hair  were  found  to  be  diseased  in  88 
per  cent,  of  the  cases,  as  follows  : 

Atrophied  and  bound  down,    2  Sweating  head,  5  cases. 

cases.  Heat  of  head,  4  cases. 

Canities,  4  cases.  Pityriasis,  1(»  cases. 

Eczema  capitis  eight  years  before  Seborrhea  oleosa,  3  cases. 

hair-fall,  1  case.  Seborrhoea  sicca,  55  cases. 

Seborrhoea  congestiva,  2  cases.  Fragilitas  crinium,  2  cases. 

In  46  per  cent,  of  the  cases  there  was  a  history  of 
baldness  in  the  family,  as  follows  : 


110  DISEASES  OF  THE  HAIR  AND  SCALP. 

Men.  Women. 

Father  only 7  cases. 

Father  and  paternal  uncle  2  ** 

"        "  "       cousins 1  *' 

"        '*  "       grandfather  and  brothers 1  " 

"        "    brothers 4  " 

"      brother,  and  maternal  aunt 1  case. 

'*      and  maternal  uncles 1    ** 

"      mother,  and  brother ..2  "  3    '* 

Paternal  uncle  and  brothers 1  " 

"  *«     3  '* 

"  "  maternal  grandfather  and  uncles 1  " 

Mother 3  "  2    *' 

"    and  maternal  grandfather 1  "  1     ** 

•«       "     sisters 1     ** 

"      "    brothers 1    ** 

Maternal  grandfather 1  " 

'*         uncles 1  ** 

*'  ♦*    and  brother 1  " 

Brothers 2  " 

In  family  on  both  sides 4  **  1    ** 

As  possible  contributory  factors  it  was  noted  that 

1  patient  constantly  wore  a  close-fitting  cap. 

2  patients  became  worse  after  a  short  residence  at  the  seashore. 
2  smoked  to  excess. 

21  soused  their  heads  daily  in  cold  water. 

What  deductions  can  we  draw  from  the  preceding 
figures  ? 

1.  As  to  sex.  We  find  that  65  per  cent  of  the 
cases  occurred  in  men.  This  is  in  accord  with  the  well- 
known  fact  that  men  are  more  frequently  bald  than 
women.  Therefore  mascuhnity  is  a  predisposing  cause 
of  loss  of  hair. 

2.  As  to  nationahty,  no  deduction  can  be  drawn,  as 
a  preponderance  of  Americans  was  to  be  expected. 

3.  As  to  condition.  Although  we  find  61  per  cent, 
of  the  patients  were  unmarried  and  but  28  per  cent, 
were  married,  this  does  not  allow  us  to  draw  any  infer- 
ence, because  experience  teaches  that  most  men  do  not 
mind  becoming  bald  half  as  much  after  they  are  mar- 


LOSS  OF  HAIR.  Ill 

ried  as  before  they  many.  Men  tell  me  again  and 
again  that  they  would  not  mind  growing  bald  if  they 
were  married.  It  is  a  common  experience  that  men 
are  not  so  particular  about  their  personal  appearance 
after  marriage  as  before,  as  they  have  other  and  more 
important  things  to  think  of.  It  is  also  to  be  observed 
that  our  tables  show  that  the  number  of  married  and 
unmarried  women  is  the  same.  With  women  the  case 
is  different  from  what  it  is  in  men,  as  the  condition  of 
the  hair  is  for  women  a  most  important  consideration 
from  the  standpoint  of  j^ersonal  appearance,  a  fine 
head  of  hair  being  to  them  a  matter  of  pride. 

4.  As  to  occupation.  Here,  too,  I  should  hesitate  to 
draw  an  inference.  If  we  took  the  figures  alone  we 
would  be  compelled  to  think  that  doctors  were  espe- 
cially liable  to  become  bald.  It  is  certainly  suggestive 
that  26  per  cent,  of  the  cases  occurred  in  professional 
men — that  is,  in  architects,  clergymen,  dentists,  lec- 
turers, librarians,  lawyers,  and  physicians.  If  we  add 
to  these  the  five  brokers,  who  certainly  live  under  a 
constant  nervous  strain,  we  have  31  per  cent,  of  the 
cases  occurring  in  brain  workers.  This  is  not  in- 
tended to  throw  any  slur  upon  the  rest  of  the  occupa- 
tions mentioned  in  the  tables.  It,  however,  tends  to 
suggest  that  active  brain  work  does  predispose  to  loss 
of  hair. 

5.  As  to  age.  It  is  evident  from  my  tables  that  the 
majority  of  the  cases  of  loss  of  hair  begin  before  the 
thirtieth  year  of  life — namely,  GO  per  cent.  We  also 
see  that  in  07  per  cent,  of  the  men  and  31  per  cent,  of 
the  women  loss  of  hair  began  between  the  twentieth 
and  thirtieth  years.  There  is  also  a  very  marked  dif- 
ference between  the  sexes  in  the  next  decade — ISf  per 
cent,  in  men  and  31  per  cent,  in  women.  We  also  learn 
that  the  most  critical  years  are  from  the  twenty- sec- 
ond to  the  twenty- sixth.     Though  the  present  paper 


112  DISEASES  OF  THE   HAIR  AND  SCALP. 

is  not  intended  to  touch  upon  treatment,  I  would  say 
that  it  is  between  the  ages  of  twenty  and  thirty-five 
that  we  are  most  justified  in  expecting  good  results 
from  it. 

6.  As  to  the  location  of  the  loss  of  hair.  We  find 
that  4:2  per  cent,  of  the  cases  affected  the  crown  alone, 
and  13  per  cent,  affected  both  the  crown  and  temples. 
In  25  per  cent,  of  the  cases  there  was  a  general  thinning 
of  the  hair,  and  this  was  three  times  more  frequent  in 
women  than  in  men.  The  tonsure  alone  was  seen 
only  six  times,  but  it  occurred  with  the  receding  tem- 
ple eleven  times.  These  figui'es  bear  out  the  well-ob- 
served fact  that  the  top  of  the  head  is  the  location  of 
baldness. 

7.  As  to  comphcating  diseases.  In  only  52  per  cent, 
of  the  cases  did  this  factor  enter  into  the  field  of  our 
study.  Of  these,  anemia,  or  diseases  inducing  anae- 
mia, constituted  nearly 79  percent. — namely,  anaemia, 
chorea,  constipation,  dyspepsia,  endometritis,  gout, 
headaches,  malaria,  metrorrhagia,  overtraining,  sper- 
matorrhoea, menopause,  chronic  urethritis,  and  uterine 
fibroids.  Acute  and  general  constitutional  diseases 
were  met  with  in  but  9  per  cent,  of  all  the  cases.  Sex- 
ual disorders  were  met  with  only  four  times.  A  fair 
deduction  from  these  figures  is  that  aucemia  is  a  cause, 
or  at  least  a  predisposer,  to  loss  of  hair,  and  that  the 
popular  idea  that  loss  of  hair  is  due  to  sexual  excesses 
is  wrong. 

S.  As  to  diseases  of  the  scalp  and  hair,  other  than  its 
faU.  The  scalp  was  diseased  in  82  per  cent,  of  the 
cases.  Seborrhoea  or  pityriasis  was  present  in  70  per 
cent,  of  the  cases,  and  sweating  or  heat  of  the  head 
was  seen  in  9  per  cent.  A  history  of  an  antecedent 
disease  of  the  scalp  was  seen  in  but  one  case.  From 
this  the  deductions  are  that  seborrhoea  is  a  most  active 
cause  of  loss  of  hair  ;  that  sweating  or  heat  of  head  is 


LOSS  OF  HAIR.  113 

a  far  more  important  symptom  of  danger  to  the  hair 
than  writers  on  baldness  have  commented  on  ;  and 
that  an  antecedent  disease  of  the  scalp,  other  than 
seborrhoea,  is  by  no  means  so  common  as  Pincus  would 
have  us  believe. 

9.  As  to  heredity.  In  4G  per  cent,  of  the  cases  there 
was  a  history  of  baldness  in  the  family.  It  is  certainly 
a  most  surprising  fact,  brought  out  by  my  tables,  that 
in  all  the  cases  of  loss  of  hair  in  women  there  is  a  dis- 
tinct history  of  the  affection  occurring  on  the  maternal 
side  ;  while  in  the  thirty-five  cases  in  which  there  is 
no  history  of  maternal  heredity  the  men  only  are  af- 
fected. It  will  be  interesting  to  note  if  further  statis- 
tical studies  show  the  same  results.  From  the  tables 
now  presented  it  is  fair  to  deduce  that  loss  of  hair  is 
markedly  hereditary,  and  that  it  tends  to  descend  in 
the  same  sex. 

10.  As  to  contributing  factors.  In  21  per  cent,  of 
the  cases  we  find  a  history  of  daily  sousing  the  head. 
This  is  by  no  means  as  great  a  percentage  as  is  given 
by  some  other  observers,  but  still  great  enough  to  sug- 
gest that  the  habit  is  detrimental  to  the  hair.  The 
other  factors  noted  are  so  few  as  to  be  useless  for  de- 
ductions. They  would  tend  to  show,  however,  that 
the  popular  idea  that  wearing  close-fitting  head  gear 
is  a  frequent  cause  of  loss  of  hair  is  not  true. 

Summary. — From  the  foregoing  study  of  loss  of 
hair  we  can  summarize  as  follows  : 

1.  Men  are  far  more  prone  to  baldness  than  are 
women,  the  proportion  being  as  G5  to  35. 

2.  Neither  the  married  nor  the  unmarried  state  exer- 
cises any  influence  in  the  production  of  baldness. 

3.  It  is  probable  that  active  brain  work  and  nervous 
mental  strain  predispose  to  baldness. 

4.  The  majority  of  the  cases  of  baldness  occurring 
before  middle  life  do  so  between  the  twentieth  and 


114  DISEASES   OF   THE  HAIR  AXD   SCALP. 

thirtieth  years  ;  and  this  is  more  marked  in  men  than 
in  women. 

5.  Anaemia,  or  diseases  that  predispose  thereto,  are 
active  causes  of  baldness. 

6.  Seborrhoea  in  all  its  forms  is  an  active  cause  of 
baldness. 

7.  Sweating  and  heat  of  head  may  be  regarded  as 
danger  signals,  foreshadowing  loss  of  hair. 

8.  Heredity  is  a  pronounced  predisposing  factor  of 
baldness,  and  it  shows  a  tendency  to  descend  in  the 
same  sex. 

9.  The  daily  sousing  of  the  head  is  pernicious  to  the 
preservation  of  the  hair. 

The  study  of  etiology  is  helpful  chiefly  as  it  teaches 
us  how  better  to  treat  diseases.  From  the  analysis  of 
the  causes  of  loss  of  hair,  as  here  given,  we  may,  I 
think,  learn  that  it  is  essential  for  us  to  put  our  pa- 
tients who  are  losing  their  hair  in  the  best  possible 
physical  condition  ;  to  cure,  or  at  least  alleviate,  any 
disease  of  the  scalp  that  may  be  present ;  and  to  forbid 
their  sousing  the  head  in  water. 


CHAPTER  YII. 

ALOPECIA  AREATA. 

Synonyms:— Area  Celsi,  (v.  Barensprimg) ;  Area  oc- 
cidentalis  diffluens,  serpens,  seu  tyria;  Alopecia  cir- 
cumscripta, (Fuchs);  Alopecia  occidentalis,  (Wilson); 
Porrigo  seu  tinea  decalvans,  (Bateman) ;  Vitiligo  capitis, 
(Cazenave);  Ophiasis;  Phytoalopecia,  (Gruby);  Teigne 


Alopecia  Areata. 

pelade,  (Bazin);  Pelade  acromatosa;  Pelade  decalvante, 
or,  ofiasica;  Pelade  (Fr.);  Die  kreisfleckige  Kahlheit, 
(Ger.);  Circumscribed  baldness,  (Eng.). 

Definition. — A  disease  of  the  hair  characterized  by 
its  sudden  fall  and  the  production  of  perfectly  bald, 
smooth,  usually  circumscribed  and  circular  patches  ; 
which  generally  affects  the  scalp,  but  may  invade 
other  hairy  parts;  runs  a  chronic  course  without  con- 


116  DISEASES   OF   THE   HAIR   AND   SCALP. 

coniitant  symptoms,  and  tends  towards  spontaneous 
recovery. 

Symptoms. — The  disease  usually  begins  suddenly, 
the  patient  finding  to  his  surprise  a  bald  circular  spot 
upon  the  head  without  knowing  when  it  formed.  In 
a  number  of  cases  there  wiU  be  a  history  of  severe, 
often  periodic,  and  localized  headache  preceding  the 
hair-faU  for  weeks  or  months.  In  other  cases  some 
shght  prmitus,  burning,  or  pain  may  ante-date  the 
alopecia.  In  any  event  the  patch  forms  suddenly,  the 
hair  falling  out  at  once.  The  size  of  the  patch  varies; 
it  may  be  very  smaU,  even  pea-sized,  or  it  may  be  as 
large  as  the  palm  of  the  hand.  When  it  exceeds  the 
latter  size,  it  is  usually  formed  by  the  coalescence  of 
smaller  patches.  It  tends  to  gain  its  fuU  size  at  once 
and  to  remain  circumscribed,  but  in  some  cases  it 
pushes  out  into  the  surrounding  parts,  either  preserv- 
ing its  circular  shape,  or  becoming  irregular  or  serpi- 
ginous. There  may  be  only  one  patch,  but  more  com- 
monly there  are  two  or  three  patches,  which  appear 
simultaneously  or  successively.  The  shape  of  the  patch, 
while  usually  oval  or  round,  may  be  in  stripes  or  bands. 
This  is  seen  most  often  after  injuries  to  the  scalp,  as  in 
ScHUTz's  case  (210  ap.)  resulting  from  injury  to  the  scalp 
by  barbers'  shears.  This  irregular  form  of  the  patches 
is  sometimes  called  alopecia  neurotica  by  those  who 
believe  that  the  usual  form  of  the  disease  is  parasitic. 
The  disease  most  frequently  affects  the  scalp  and  may 
be  symmetrical.  Its  next  most  common  seat  is  the 
beard.  It  may,  however,  affect  all  the  hairy  parts  of 
the  body,  and  in  some  cases  cause  universal  baldness. 

The  appearance  of  the  disease  is  striking,  and  not 
readily  forgotten  when  once  seen.  The  bare  rounded 
spot  stands  out  conspicuously  from  amongst  the  sur- 
rounding hair.  It  is  perfectly  bald  and  smooth,  with- 
out any  scaliness.      In  some  cases  there  are  a  few 


ALOPECIA   AREATA.  117 

black  points  in  the  patch,  which  have  been  taken  for 
broken-off  hairs,  but  are  really  the  remains  of  hair- 
roots  which  have  not  fallen  out.  In  some  cases  there 
will  be  a  few  straggling  hairs  remaining.  It  seems 
as  if  the  patch  was  depressed  and  atrophied,  but  this 
appearance  is  probably  due  to  the  fact  that  the  hair 
and  roots  have  fallen  out  of  the  part.  In  color,  the 
affected  area  in  its  earlier  stages  may  be  slightly  red- 
dened from  hyperaemia,  but  in  most  of  the  cases  that 
we  meet  with,  it  is  white  and  polished.  To  the  touch 
the  skin  seems  soft  and  pliable.  Sensation  may  be 
normal  in  the  patch,  but  often  somewhat  blunted,  as 
shown  by  the  amount  of  stimulation  the  diseased 
surface  will  tolerate. 

The  hairs  at  the  margin  of  the  patch  at  first,  and  if 
the  disease  is  spreading,  will  be  loose,  dry,  brittle, 
atrophied  at  the  root  and  come  out  readily  on  slight 
traction.  Later,  and  when  the  patch  has  attained  its 
fuU  development,  they  wiU  be  firmly  seated  in  their 
foUicles,  and  normal  in  appearance. 

Recovery  will  be  indicated  by  the  appearance  of  fine 
lanugo  hairs  in  the  patch.  These  may  fall  out  again 
to  be  followed  by  a  new  crop  of  white  hair,  which  will 
remain  and,  growing  stronger,  develop  into  strong 
colored  hairs.  Kaposi  says  that,  if  the  disease  has 
been  severe  and  general,  restitution  of  the  hair  will 
not  take  place;  and  that  even  in  milder  cases  it  may 
go  no  further  than  the  production  of  lanugo  hairs. 
The  disease  is  comparatively  rare.  Neumann  describes 
a  form  of  this  disease  in  which  there  is  marked  anaes- 
thesia of  the  scalp. 

Some  of  the  French  authors,  judging  from  their  de- 
scriptions, would  seem  to  have  an  entirely  different 
idea  of  alopecia  areata  than  we  have,  and  to  have  con 
founded  it  with  other  diseases.     Thus,  Cazenave  (48) 
describes  cases  in  which  a  change  in  the  color  of  the 


118  DISEASES   OF   THE   HAIR  AXD  SCALP. 

hair  took  i^lace,  and  designates  the  disease  vitihgo 
capitis.  This  is  probably  the  pseudo-pelade  of  some 
French  authors.  Gruby  (211)  says  that  the  patches 
are  covered  with  a  whitish  dust  formed  entirely  of 
cryptogamia.  Hardy  considers  the  disease  as  having 
two  stages  :  First,  an  early  parasitic  contagious  stage  ; 
and  second,  a  neuropathic  stage  in  which  the  parasite 
has  disappeared.  Courreges  (53)  regards  the  disease 
as  having  three  stages  :  First,  one  in  which  there  is 
discoloration  of  the  skin  and  fall  of  the  hair,  itch- 
ing of  the  scalp  and  pityriasis.  This  stage  is  short. 
Second,  the  appearance  on  the  bald  spots  of  delicate 
downy  hairs.  This  period  may  last  for  years.  Third, 
the  period  of  recovery  and  growth  of  strong  hair. 
Further,  he  makes  two  varieties  of  alopecia  areata, 
namely  :  la  pelade  achromateuse,  and  la  pelade  decal- 
vante.  The  first  is  the  porrigo  decalvans  of  Bateman, 
and  the  vitiligo  de  cuir  chevelu  of  Cazexave.  It  cor- 
responds to  our  usual  and  typical  form  of  alopecia 
areata.  The  second  form  is  one  in  which  a  rapid  fall 
of  the  hair  of  the  whole  head  or  body  takes  place,  and 
corresponds  to  what  we  should  regard  as  an  unusually 
marked  form  of  the  disease.  Courreges'  views  as  to 
these  divisions  are  not  peculiar  to  himself,  but  are 
quite  commonly  held  by  French  authors.  Bazin  (190) 
affirms  that  true  pelade  (alopecia  areata)  is  very  rare, 
but  that  there  is  a  false  form  which  is  often  the  con- 
sequence of  tinea  tonsurans  badly  treated  or  left  to 
itself. 

The  disease  has  a  tendency  to  recur,  and  sometimes 
is  hereditary.  Tmx  (257)  reports  a  case  in  which  a 
father  and  three  of  his  children  had  the  disease  ;  and 
Hard  A  WAY  (216)  has  met  T\ith  two  cases  in  which 
relapses  took  place  in  the  Spring  of  successive  years 
and  attacked  new  areas  each  time. 

Etiology.— The  etiology  of  this  disease  has  been  a 


ALOPECIA    AREATA.  119 

field  of  battle  for  many  years,  and  dermatologists  are 
divided  into  two  great  camps  in  regard  to  the  question 
of  its  being  parasitic  or  non-parasitic.  The  large  ma- 
jority of  the  older  authorities  are  against  the  parasitic 
theory  ;  thus  of  forty-two  authors  consulted  as  to  this 
point,  and  they  were  taken  without  selection,  fifteen 
were  for  the  parasitic  theory,  and  twenty-seven  against 
it.  In  the  first  group  were  such  men  as  Anderson,  T. 
Fox,  Thin,  Gruby,  Bazin,  Hardy,  and  Eichhorst ;  in 
the  second  group,  Duhring,  Kaposi,  Neumann,  Schwim- 
mer,  Michelson,  Veiel,  Yidal,  Horand,  Duckworth,  Pye- 
Smith,  Liveing  and  Wilson  were  found.  Gruby  (211:) 
was  the  first  to  allege  a  parasitic  origin  for  the  disease, 
and  in  1843  described  the  parasite,  which  he  named 
''  Microsporon  Audouini.''^  Bazin,  in  1862,  brought 
forward  the  claim  of  ''  Microsporon  Decalvans^^  to  the 
honor  of  being  the  cause  of  the  disease.  Thin  (529),  in 
1881,  described  yet  another  fungus  in  this  disease  which 
he  called  ''  Bacterium  Decalvans.''^  Von  Sehlen  (2G7) 
in  1885  entered  the  field  as  the  discoverer  of  the  para- 
site in  alopecia  areata.  Robinson  (215  ap.)  in  1887  also 
described  a  coccus  as  the  cause  of  the  disease. 

It  is  true  that  a  single  positive  result  from  the  study 
of  a  disease  is  of  vastly  more  value  than  many  nega- 
tive ones,  and  we  should  have  the  etiology  of  alopecia 
areata  settled  upon  a  firm  foundation  if  the  positive 
results  of  those  who  believe  that  they  have  found  a 
parasite  were  in  accord.  But  they  are  not,  as  will 
be  seen  further  on  when  discussing  the  pathology  of 
the  disease.  Such  disparity  in  the  findings  of  the  in- 
vestigators of  this  disease,  and  the  fact  that  many 
other  well-trained  and  expert  workers  in  pathological 
histology  have  sought  for  the  parasite  and  have  not 
found  it,  are  in  striking  contrast  to  what  obtains  in 
the  other  parasitic  diseases  of  the  skin.  At  present  we 
are  forced  to  acknowledge  that  there  is  not  sufficient 


120  DISEASES   OF  THE   HAIR   AND   SCALP. 

evidence  offered  to  warrant  us  in  regarding  this  dis- 
ease as  a  dermato-mycosis.  Besides  the  absence  of 
proof  of  the  presence  of  a  parasite,  the  suddenness  of 
onset  of  the  disease,  its  occasioDal  general  appearance, 
and  the  want  of  any  trace  of  fungous  growth  or  debris 
upon  the  affected  areas,  are  all  against  the  parasitic 
theory.  Dermato-mycoses  are  slow  in  development, 
usually  appear  primarily  in  a  number  of  small  foci, 
and  do  not  involve  the  whole  surface  at  once,  and 
generally  scales  or  crusts  are  present  upon  the  diseased 
areas. 

The  most  probable  cause  of  the  disease  is  a  tropho- 
neurosis. It  is  true  that  no  nerve  lesion  has  yet  been 
demonstrated  in  connection  with  the  disease.  But  the 
sudden  onset  of  the  malady,  all  the  hairs  in  a  given  area 
being  at  one  and  the  same  time  loosened,  seems  to 
indicate  that  some  profound  disturbance  in  tlie  nutri- 
tion of  the  affected  part  has  taken  place,  probably 
dependent  upon  some  trophic  nerve  disturbance.  The 
neurotic  theory  of  the  disease  finds  further  support  in 
the  occurrence  of  periodic  headachea  and  disturbances 
of  sensation  before  the  outbreak  ;  in  the  presence  of 
anaesthesia  in  the  patches  to  a  greater  or  less  degree  ; 
in  its  frequent  occurrence  in  children  who  have  unstable 
nervous  systems  ;  in  its  following  upon  severe  nervous 
shock  and  injuries  to  the  scalp.  Uchermaxn  (263)  has 
reported  a  case  of  alopecia  areata  in  a  boy  which  fol- 
lowed a  blow  on  the  head  with  a  stone,  and  involved 
the  w^hole  head.  Michelsox  (231)  has  met  with  a  case 
following  a  fall.  Tyson  (202)  has  recently  reported 
three  cases  of  complete  faU  of  the  hair  following 
rapidly  upon  nervous  shock.  Michelson  (231)  also 
suggests  that  the  disease  may  be  due  to  a  closure  of 
the  cutaneous  vessels  of  the  affected  area,  and  conse- 
quent interference  with  nutrition,  the  closure  being 
due  to   a  connective-tissue  increase  of  the  intima. 


ALOPECIA  AREATA.  121 

It  is  possible  that  the  neurosis  may  express  itself  in  a 
constricting  action  upon  the  blood-vessels,  either  those 
going  to  the  middle  follicle  region  or  to  the  papilla, 
and  a  consequent  preponderance  in  the  productivity  of 
one  or  the  other  region,  and  a  fall  of  the  hair.  Joseph 
(223)  has  recently  produced  in  cats  lesions  exactly  re- 
sembling alopecia  areata  in  man,  by  cutting  out  the 
second  cervical  ganglia.  His  experiments  have  been 
repeated  by  others  with  similar  results.  Mibelli  (198 
ap.)  found  that  cutting  the  second  cervical  nerve  with- 
out extirpating  the  ganglion  was  sufficient,  and  that 
the  fall  of  hair  was  not  confined  to  the  district  sup- 
plied by  the  nerve,  but  was  seen  in  regions  supplied 
by  other  nerves.  Poxtoppidan  (200  ap.)  saw  typical 
patches  of  alopecia  areata  follow  the  operation  for  re- 
moval of  an  enlarged  cervical  gland  in  the  left  carotid 
region.  In  further  support  of  the  neurotic  theory 
AsKANAZY  (llT  ap.)  cites  a  case  following  removal  of  a 
tumor  from  the  right  submaxillary  region  and  attended 
by  facial  paralysis  ;  and  another  of  a  hyp(3chondriac 
who  suffered  from  severe  headache  and  burning  of  the 
top  of  the  head. 

The  disease  is  comparatively  rare.  Bulkley  met 
with  it  one  hundred  and  nineteen  times  in  twelve 
thousand  cases  occurring  in  New  York  city.  It  would 
seem  to  be  rathea^more  common  in  Glasgow,  Anderson 
having  had  one  hundred  and  fifty-three  cases  in  ten 
thousand.  In  London  Radcliffe-Crocker  met  with 
it  two  hundred  and  fifty -three  times  in  ten  thousand 
public  cases,  and  eighty-two  times  in  two  thousand 
private  cases.  His  youngest  patient  was  three  years 
old.  It  befalls  both  sexes,  though  it  is  more  common 
in  males.  Children  are  often  affected  with  the  disease. 
They  formed  about  one-sixth  of  Bulkley's  patients. 
According  to  his  tables,  the  disease  in  the  upper  classes 
is  most  frequent  between  the  ages  of  twenty  and  forty, 
no  fewer  than  twenty-five  out  of  thirty-five  cases  oc- 


122  DISEASES  OF  THE   HAIR  AND  SCALP. 

curring  between  those  ages.  He  met  with  it  much  less 
frequently  in  public  than  in  private  practice.  I  have 
met  ^vith  the  disease  twenty-nine  times  in  four  thou- 
sand consecutive  cases  in  dispensary  practice  up  to  1887. 
Of  the  patients,  seventeen  were  males  and  twelve  fe- 
males. The  majority  of  the  cases  occurred  between 
the  twentieth  and  fortieth  year  of  age,  namely,  eight- 
een. There  were  ten  patients  under  twenty  years  of 
age,  and  but  one  was  over  forty.  The  youngest  was 
a  girl  of  five  years,  and  the  oldest  a  man  of  forty-four 
years. 

Up  to  comparatively  recent  times  the  disease  was  not 
considered  contagious.  The  most  earnest  advocates 
of  the  contagiousness  of  the  disease  are  the  French. 
BucHiN  (1:6  ap.)  cites  a  number  of  cases  of  contagion. 
Vaillard  and  Vixcext  (225  ap.)  report  an  outbreak 
of  the  disease  in  which  forty-four  soldiers  w^ere  at- 
tacked. Clemexceau  de  la  Loquerie  (53  ap.)  gives 
many  like  instances,  as  in  a  school  in  Amiens  in  which 
fifty  out  of  four  hundred  children  had  the  disease, 
and  an  epidemic  of  eighty  cases  in^  a  regiment  at 
Montpellier.  He  regards  the  modes  of  conveyance  to 
be  by  the  barbers'  shears,  wearing  of  infected  caps, 
cushions  of  public  conveyances,  and  the  like.  Feulard 
(170  ap.)  reports  the  occurrence  of  forty -four  cases  in 
one  company  of  a  regiment  stationed  in  Paris,  and 
states  that  in  18!U  and  1802  it  occurred  in  the  propor- 
tion of  about  3.30  per  1,000  of  the  army.  He  thinks 
that  the  liair  clipper  is  responsible  for  its  prevalence. 
It  is  most  frequent  in  the  cities.  In  Germany  Eichhoff 
(168  ap.)  reports  several  instances  of  apparent  con- 
tagion. Crocker  and  HtllierIu  England  also  report 
cases  of  contagion.  In  this  country  the  only  epidemic 
of  a  disease  simulating,  if  not  identical  with,  alopecia 
areata  is  reported  by  Putxam  (210  ap.)  as  occurring  in 
an  asylum  for  girls  near  Boston.  The  cases  were  ex- 
amined by  Drs.  White  and  Bowen  of  Boston.     In  this 


ALOPECIA  AREATA.  *  123 

epidemic  sixty  out  of  sixty-five  girls  were  attacked  by 
the  disease.  Morrow  has  also  met  with  cases  appa- 
rently contagious.  In  the  light  of  these  observations, 
it  seems  impossible  to  deny  that  the  disease  is  conta- 
gious at  times.  It  is  equally  impossible  to  assume  that 
errors  in  observation  have  been  made  in  all  these  cases. 

Contagiousness  of  the  disease  is,  however,  contrary 
to  the  experience  of  most  observers,  and  at  best  is  a 
rare  exception.  The  disease  has  been  seen  in  the  same 
patient  coincidently  with  ringworm  of  the  head,  and 
probably  such  occurrences  have  led  to  mistakes  in 
diagnosis.  The  ^Hinea  decalvans"  of  Tilbury  Fox, 
in  which  perfectly  bald  circumscribed  spots  occur  with 
parasites  in  the  neighboring  hairs,  may  have  been  of 
this  kind.  Liveing  (220)  thinks  that  it  is  just  possible 
that  trichophytosis  may  in  some  cases  so  interfere 
with  the  nutrition  of  the  hair  as  to  favor  the  subse- 
quent development  of  alopecia  areata.  Alder  Smith 
(79)  draws  attention  to  the  fact  that  a  patch  of  tricho- 
phytosis capitis  may  be  changed  into  a  perfectly  bald, 
smooth  place  by  tlie  apphcation  of  an  ethereal  solu- 
tion of  boracic  acid.  There  seems  to  be  some  relation 
between  alopecia  areata  and  ringworm,  as  in  a  country 
where  one  is  common  the  other  abounds.  Until  fur- 
ther light  is  thrown  on  the  subject,  it  is  probably  best 
to  hold  that  there  are  some  cases  that  are  contagious 
and  may  be  parasitic,  and  some  that  are  non-conta- 
gious and  neurotic. 

The  following  are  considered  to  be  predisposing 
causes,  viz. :  The  nervous  diathesis  ;  disturbances  of 
the  general  nutrition  of  the  body,  as  from  recent  con- 
stitutional syphilis  (Squire,  34  a);  menstrual  disorders 
(Nayler,  52);  arsenic  (Wyss,  272);  parturition  and 
pregnancy  (Graham,  213).  De  Tullio  (1G7  ap. )  reports 
a  case  of  progressive  spread  of  the  disease  in  a  sus- 
pected case  of  syphilis  in  which  the  iodide  of  mercury 
had  been  administered  during  three  years. 


1^4  DISEASES   OF   THE   HAIR  AND   SCALP. 

Pathology. — Hairs  extracted  from  the  margin  of 
an  advancing  patch  of  alopecia  areata  show  marked 
atrophic  change,  and  are  seen  to  terminate  abiniptly 
in  a  pear  or  chib-shaped  extremity.  Sometimes  a  por- 
tion of  the  root  sheath  is  attached  to  the  phicked 
hair,  sometimes  not.  As  we  approach  the  free  end  of 
the  hair  an  oval  swelling  will  someti7nes  be  fonnd  ta- 
pering again  towards  the  extremity  of  the  hair,  which 
is  often  spht.  Duhrixg  (202)  draws  attention  to  the  fact 
that  these  changes  differ  from  those  found  in  senile 
alopecia  only  in  the  suddenness  of  their  occurrence. 
Sometimes  ampullary  sweUings  are  found  near  the  root, 
composed  of  a  concentration  of  granular  pigment 
matter;  and  sometimes  there  are  adherent  folhcular 
and  sebaceous  matters  round  the  shaft.  Below  the 
swelling  a  stricture  is  apparent,  which  again  passes 
into  the  deeper  bulb  elements  above  the  papilla  and 
at  the  base  of  the  sac.  Sometimes  bright  refracting 
granules  are  seen  investing  the  hairs,  which  are  not 
easily  removable  by  ether,  and  no  doubt  suggested  the 
fungus  theory,  but  are  in  reality  fatty  particles.  The 
swelhng  of  the  cuticular  scales  of  the  hair  simulates 
a  fung-us.  DuHRiXG  (2<  )2)  says  that  what  is  described 
as  the  microsporon  Audouini  is  an  accumulation  of 
an  appreciable  amount  of  sebaceous  matter,  broken  up 
epidermic  scales,  and  debris  about  the  roots  of  the 
han;  further,  that  sebum  when  subjected  to  a  reagent 
has  a  tendency  to  split  and  break  up  into  fine  particles, 
which  adhere  so  closely  and  with  such  tenacity  to  the 
hair  as  to  accurately  resemble  spores. 

According  to  Giovaxxixi  (175  ap.)the  disease  begins 
by  a  perivascular  infiltration  by  leucocytes,  especially 
about  the  lower  part  of  the  hair-follicle,  where  they 
invade  the  circular  connective-tissue  layer.  From 
there  they  often  enter  between  the  cells  of  the  matrix, 


ALOPECIA   AREATA.  125 

internal  root-sheath,  lower  part  of  the  neck  of  the 
hair,  or  both  root-sheaths.  Either  in  the  matrix  or 
internal  root-sheath  of  the  infiltrated  hairs  the  cells 
undergo  karyokinesis,  diminishing  in  number  until 
they  disappear  completely.  At  the  same  time  the 
cells  of  the  matrix,  neck  of  the  hair,  and  internal  root- 
sheath  degenerate.  Degeneration  is  accompanied  by 
disappearance  of  pigment.  Destruction  of  the  hair-bulb 
follows,  and  then  that  of  the  neck  of  the  follicle  and 
the  internal  root-sheath.  The  follicle  itself  atrophies, 
but  usually  not  to  the  degree  of  destruction.  A  new 
hair  generally  forms  in  the  follicle,  unless  infiltration 
continues,  in  Avhich  case  it  will  fall.  If  the  process 
becomes  chronic  the  follicle  and  the  sebaceous  glands 
will  eventually  be  destroyed. 

All  those  who  describe  the  parasite  in  this  disease  give 
explicit  directions  as  to  the  preparation  of  the  hair  for 
examination,  and  lay  great  stress  upon  the  difficulty 
of  finding  the  fungus.  Gruby  (214)  described  the 
parasite  as  follows:  The  cryptogam ia  are  arranged 
so  as  to  form  a  tube  or  vegetable  sheath  about  the  hair. 
They  consist  of  trunk,  branches,  and  sporules.  The 
trunks  have  an  undulated  form  following  the  direction 
of  the  hair  fibres,  are  transparent,  and  have  a  diameter 
of  .002  to  .003  mm.  They  bifurcate  at  times,  giving 
off  branches  at  an  angle  of  thirty  to  fifty  degrees.  The 
branches  are  distinguished  from  the  trunk  by  the 
sporules  which  accompany  and  cover  them.  The 
sporules  are  oval  or  round,  the  diameter  of  the  former 
being  0.002  to  0.008  mm.,  and  of  the  latter  0.001  to 
0.005  mm.  They  are  transparent,  and  do  not  contain 
molecules  in  their  interior,  and  swell  in  water.  These 
are  the  microsporon  Amlouini.  They  commence  to 
develop  at  the  surface  of  the  hair,  1  to  2  mm.  from 
the  epidermis.     They  are  first  seen  parallel  to  the  axis 


126  DISEASES   OF  THE  HAIR  AND  SCALP. 

of  the  hail',  and  spread  by  immediate  contact  from 
hair  to  hair.  Bazix  (190)  gives  a  similar  description. 
T.  Fox  (210)  says  the  fmigus  occm-s  in  the  form  of 
very  dehcate  waxy  mycehal  threads.  Thin  (259)  fomid, 
after  careful  preparation,  minute  round  or  elongated 
rounded  bodies  in  the  hairs  which  resembled  in  shape 
and  refractive  power  his  ^ '  bacterium  foetidum. ' '  These 
he  believes  are  tlie  cause  of  the  disease,  and  names 
^^  bacterium  decalvans.^^  They  were  in  position  and 
arranged  so  as  to  show  that  they  were  distinct  from 
the  rows  and  aggregations  of  minute  granules  which 
are  found  in  healthy  hairs.  They  were  found  fre- 
quently in  pairs,  the  long  axis  of  each  member  of  a 
pair  forming  a  continuous  line.  Sometimes  tlij-ee 
were  found  end  to  end,  with  the  appearance  of  one 
continuous  sheath  for  the  three.  Malassez  (22S)  de- 
scribes the  spores  as  occm-ring  in  the  epidermic  scales, 
in  the  superficial  layers  of  the  epidermis,  and  occa- 
sionally upon  the  hair.  According  to  him  they  are 
spherical  or  ovoid  highly  refractive  bodies,  not  larger 
than  4  to  5  mm.  They  are  double  contoured  and 
many  small  buds  project  from  their  circumference. 
Some  smaller  spores  (2  mm.)  were  without  the  double 
contour,  and  some  still  smaller  were  simply  spherical. 
They  were  found  singly  or  in  groups  or  chaplets. 
Von  Sehlen's  (267)  micrococci  were  found  in  the  root- 
sheaths  of  the  hair,  but  his  description  of  the  cases 
from  which  the  hairs  examined  were  obtained  is  so 
strikingly  hke  that  of  trichophytosis  capitis  that  we  are 
led  to  think  that  he  made  an  error  in  diagnosis;  and 
BoRDONi  Uffreduzzi  (193)  has  found  micrococci  iden- 
tical with  these  upon  the  roots  of  the  hair  of  the  nor- 
mal skin. 

The  findings  of  the  different  obseiwers  vaiy  amongst 
themselves  so  much  that  it  is  best  to  await  further 
developments  before  deciding  that  the  disease  is  para- 


ALOPECIA  AREATA.  127 

sitic.  It  is  noticeable  that  the  different  parasites  de- 
scribed are  all  superficial  to  the  skin  and  in  or  upon 
the  hair.  This  is  not  the  way  in  which  perfectly 
smooth  bald  patches  could  be  produced;  for  that  it  is 
necessary  that  the  hair  papillae  should  be  affected.  In 
this  connection  it  is  interesting  to  note  that  Nystrom 
(237)  found  spores  identical  with  those  described  by 
Malassez  upon  a  napkin  hung  in  a  moist  corner  of  a 
room,  and  therefore  regards  them  as  derived  from  the 
atmosphere.  Michelson  (231)  has  found  on  normal 
hairs  by  cultures  the  same  cocci  as  described  by  Von 
Sehlen.  He  also  found  them  on  hairs  taken  from 
the  edge  of  alopecia  areata  patches.  Thus  far  his  at- 
tempts at  inoculation  of  these  have  been  failures,  and 
he  regards  them  as  being  a  normal  condition. 

Robinson,  in  1887  (215  ap.),  is  the  first  to  describe 
cocci  deep  down  in  the  follicle  as  the  cause  of  the 
disease.  Like  Giovannini,  he  found  perivascular  infil- 
tration of  the  upper  part  of  the  corium  by  small  cells, 
affecting  the  papillary  portion.  With  this  there  was 
proliferation  of  connective-tissue  coi'puscles,  fall  of  the 
hair,  and  finally  coagulation  in  some  of  the  blood-  and 
lymph-vessels.  The  hair-roots  showed  atrophic  altera- 
tions. Lanugo  hairs  were  apparently  formed, in  the 
upper  part  of  the  follicle.  In  chronic  cases  the  follicles 
were  sometimes  hairless,  and  the  sebaceous  glands 
were  either  normal,  degenerated,  or  destroyed.  The 
areas  of  baldness  corresponded  in  size  to  the  areas 
supplied  by  the  plugged-up  blood-vessels.  In  the 
lymphatic  vessels  and  in  the  walls  of  a  few  blood-ves- 
sels he  found  small,  round,  dark  bodies  of  equal  size 
and  grouped  in  zoogloea  masses.  These  were  not  acted 
on  by  acids  or  alkalies.  They  are  cocci,  8  /<  in  diame- 
ter, and  in  size  similar  to  staphylococcus  pyogenes 
aureus.  There  were  also  some  diplococci.  These  were 
less  numerous  in  chronic  cases. 


128  DISEASES   OF  THE   HAIR  AND   SCALP. 

Dyce  Duckworth  (201)  had  the  opportunity  of 
examining  a  case  of  alopecia  areata  occurring  in 
the  person  of  a  boy  aged  thirteen  years  who  was 
drowned.  The  disease  first  came  on  when  he  was 
four  years  of  age,  and  had  gone  and  come  several  times 
since.  After  death  portions  of  the  scalp  were  carefully 
examined,  and  the  results  reported,  as  follows:  There 
was  found  to  be:  1.  A  distinct  atrophy  of  the  hair- 
f oUicles  and  the  sebaceous  glands  in  connection  with 
them.  2.  Infiltration  of  the  hair-follicles,  specially 
their  outer  root-sheath,  with  a  new  round  cell  gi'owth. 
This  growiih  appeared  to  be  perivascular,  and  tracts  of 
it  were  found  in  the  middle  layer  of  the  corium  lead- 
ing up  to  the  papillary  layer.  3.  The  hair  follicles  in 
the  affected  part  were  mostly  quite  atrophied,  their 
nourishment  having  been  cut  off  by  the  new  growth. 
In  some  instances  remains  of  the  papilla3  were  seen, 
but  the  capillary  loops  were  infiltrated  with  the  cell 
growth.  In  other  instances  the  follicles  appeared  to 
be  making  efforts  at  repair  by  throwing  out  numerous 
digitations.  4.  The  vitreous  membrane  of  the  follicles 
was  in  some  cases  hypertrophied.  5.  The  sweat  glands 
were  practically  unaffected,  though  parts  of  their  ducts 
were  imphcated  in  the  new  growth.  6.  No  parasitic 
elements  were  found. 

Wagner  and  Schultze  (21S)  have  examined  pieces 
cut  from  the  hving  scalp  with  negative  result. 

Diagnosis. — The  diagnosis  is  easy,  as  a  rule,  the  dis- 
ease presenting  so  striking  an  appearance  as  hardly  to 
be  mistaken  for  anything  else.  As  in  psoriasis,  the 
symptoms  are  so  well  pronounced  that  students,  once 
having  seen  a  case,  do  not  easily  forget  it.  Some- 
times, however,  it  may  be  difficult  to  distinguish  it 
from  ringworm  of  the  head,  and  it  must  also  be 
diagnosticated  from  favus,  from  other  forms  of 
alopecia,  and  possibly  from  vitiHgo. 


ALOl^KCIA   AREATA. 


12D 


Differential  Diagnosis  from  Trichophytosis  Capitis. 


Alopecia  Areata. 

1.  Occurs  suddenly  without 
antecedent  lesion,  and  the  patch- 
es often  attain  their  full  size  at 
once. 

2.  Patch  usually  perfectly  cir- 
cular and  does  not  contain 
"gna wed-off "  hairs,  scales,  or 
crusts,  but  is  perfectly  smooth 
and  shiny. 

3.  Hairs  about  patch  unalter- 
ed, though  at  times  they  may  be 
easily  extracted. 

4.  Occurs  only  on  hairy  parts 
of  the  body. 


5.  No  parasite    found,    or  at 
least  none  readily  detected. 


Trichophytosis  Capitis. 

1.  Begins  usually  at  one  point 
by  a  small  erythematous  papule 
or  patch,  and  spreads  from  it 
more  or  less  slowly. 

2.  Patch  more  or  less  circular, 
with  broken  and  gnawed-off 
hairs  in  it,  and  floor  covered 
with  thick,  grayish  crusts  or 
abundant  scales. 

3.  Hairs  in  and  about  patch 
ai'e  brittle,  break  easily  when 
pulled  on,  and  bend  at  an  angle. 

4.  Occurs  both  on  hairy  and 
non-hair^'^  parts  of  the  body;  and 
patch  will  sometimes  spread 
from  non-liairy  to  hairy  parts, 
or  vice  versa. 

5.  Fungus  found  abundantly 
in  har  and  scales. 


The  two  conditions  are  less  easily  distinguished 
when  ringworm  of  the  head  has  lasted  some  time, 
involves  a  large  portion  of  tlie  scalp,  and  is  in  an  in- 
active condition.  But  even  here  there  will  be  more  or 
less  scaling,  and  an  occasional  broken-off  stub  of  hair; 
and  careful  search  will  discover  the  fungus  in  the  hair 
or  scales. 

Favus  lacks  the  circular  development  of  aloi)ecia 
areata,  is  more  disseminated,  has  the  sulphur- yelloAv 
cup -like  crusts  characteristic  of  it,  or  else  the  scalp  is 
covered  with  powdery  scales.  It  developes  slowly,  is 
inflammatory  in  character,  and  leaves  cicatricial 
patches  where  it  has  run  its  course.  The  microscope 
shows  the  fungus  abundantly  in  scales,  c-i^usts,  and  hair. 

Alopecia  Senilis  and  Praematura  develop  slowly, 
beginning  either  at  the  vertex  and  spreading  forward, 
or  at  the  forehead  and  spreading  backward ,  involve  only 
the  upper  middle  region  of  the  head,  and  take  months 
or  years  to  produce  complete  baldness.  There  is  often 
a  history  of  preceding  disease  of  the  scalp,  su(*h  as 
seborrhoea.      In  alopecia  areata  the  baldness  occurs 


180  DISEASES  OF  THE  HAIR  AND   SCALP. 

suddenly,  occupies  the  lateral  parts  of  the  head  quite 
as  often  as  other  regions,  and  generally  there  is  no 
antecedent  disease  of  the  scalp.  If  it  involves  the 
greater  part  of  the  head,  there  will  yet  be  the  history 
of  distinct  patches  at  the  begining. 

Sometimes  syphilitic  alopecia  will  present  appear- 
ances very  much  like  alopecia  areata.  In  syphilis  we 
meet  with  two  forms  of  baldness,  one  occurring  as  the 
result  of  the  cachexia  of  the  disease,  and  the  other  from 
the  absorption  or  breaking  down  and  ulceration  of  a 
syphilide.  The  first  form  sometimes  resembles  a  severe 
case  of  alopecia  areata,  affecting  more  or  less  generally 
the  whole  head,  and  causing  great  loss  of  hair.  It 
differs  from  it  in  giving  a  characteristically  ragged 
look  to  the  head,  and  in  showing  no  tendency  to  the 
formation  of  circles.  The  history  of  the  case  will  aid 
in  making  the  diagnosis.  Should  there  be  any  cuta- 
neous manifestations  of  syphilis  present,  the  decision 
will  be  easily  reached.  The  second  form  of  alopecia 
syphihtica  resulting  from  ulcerating  lesions  is  differ- 
entiated from  alopecia  areata  by  its  history  and  by  the 
cicatricial  tissue  present. 

Bald  spots  arising  from  liurns  and  other  injuries  to 
the  scalp  should  offer  no  difficulty  in  diagnosis;  their 
history  and  cicatricial  appearance  show  their  origin. 

Vitiligo  should  not  be  confounded  with  alopecia 
areata.  It  is  a  disease  affecting  only  the  color  of  the 
hair. 

Prognosis.— The  disease  tends  to  recover  spontane- 
ously, especially  in  yomig  people.  In  older  people 
the  prognosis  is  not  so  good.  Neumann  (27)  says  the 
outlook  in  the  anaesthetic  form  is  bad;  and  the  serpi- 
ginous form  is  considered  by  Squire  (34a)  to  be  of  less 
favorable  prognosis  than  the  circular  form.  Cases  of 
general  alopecia,  especially  those  coming  on  suddenly, 
are   more  grave  than  the  circumscribed  cases.     The 


ALOPECIA  AREATA.  131 

duration  of  the  disease  is  variable.  Eecoveiy  has 
taken  place  in  six  weeks,  but  this  is  exceptional. 
From  six  months  to  two  years  may  be  given  as  a  rea- 
sonable time  in  which  to  look  for  recovery.  The  pa- 
tient should  be  apprised  of  the  tendency  the  disease 
has  to  relapse.  Cases  of  universal  alopecia  are  of  bad 
prognosis  and  often  never  recover. 

Treatment. — Many  of  thesuiferers  from  this  malady 
show  some  indication  for  the  exhibition  of  tonics. 
When  occurring  in  children  they  will  often  be  found  to 
be  anaemic.  They  should  be  taken  out  of  school  and 
allowed  plenty  of  air  and  exercise  until  they  attain  to 
a  better  degree  of  health.  Cod-liver  oil,  iron,  phos- 
phorous, arsenic,  and  quinia  are  the  drugs  most  indi- 
cated as  tonics.  The  use  of  phosphate -bearing  food 
is  advised  by  some,  as  oatmeal,  cracked  wheat  and 
the  like.  We  should  endeavor  to  place  our  patients 
under  the  best  possible  conditions,  to  relieve  them  as 
far  as  may  be  from  all  sources  of  anxiety,  and  to, 
alter  anything  that  may  be  wrong  on  the  side  of  the 
general  economy. 

The  local  treatment  consists  in  stimulation  of  the 
scalp.  In  the  beginning  of  treatment  it  is  well  to  re- 
move by  epilation  all  the  loose  hairs  about  the  margins 
of  the  patches.  The  best  method  of  effecting  this  is 
by  pulling  the  hair  between  the  thumb  and  an  ordi- 
nary spatula  or  stout  card  held  in  the  hand.  This  pro- 
cedure sometimes  seems  to  check  the  further  growth 
of  the  patch. 

For  stimulants,  carbolic  acid ;  tincture  of  cantharides; 
cantharidal  collodion  ;  tincture  of  nux  vomica,  vera- 
trine,  capsicum,  phosphorus,  or  aconite  ;  suli)hate  of 
quinine;  strychnine;  liquor  ammonise  fortior;  sulphur; 
bichloride  ;  yellow  sulphate,  and  oleate  of  mercury ; 
croton-oil  and  castor-oil,  each  and  all  have  their  advo- 


132  DISEASES   OF   THE   HAIR  AXD   SCALP. 

cates,  and  are  used  either  separately  or  two  or  more 
of  them  combined.  As  the  diseased  scalp  will  bear, 
as  a  inile,  a  good  deal  more  stimulation  than  the  healthy 
scalj),  we  must  regulate  the  strength  of  our  chosen 
stimulant  solely  by  the  amount  of  reaction  it  causes. 
Thus,  liquor  ammonice  fortior,  in  full  strength,  may 
be  freely  aj^plied  to  the  scalp,  and  its  use  persisted 
in  for  weeks  without  apparent  OTer-irritation  of  the 
scalp.  As  our  object  is  simply  stimulation,  I  can  see 
no  reason  for  combining  any  of  the  above-mentioned 
stimulants,  excepting  that  the  castor- oil  may  be  used 
as  an  eligible  excipient  for  some  other  remedy.  We 
may  choose  as  a  vehicle  for  the  stimulant  either  an 
oil,  an  ointment,  lard,  vasehne,  or  water.  It  is  well 
to  change  oui-  stimulant  from  time  to  time. 

Good  results  have  been  reported  from  the  use  of 
electricity,  the  galvanic  current  being  used  with  one 
pole  at  the  nape  of  the  neck,  and  the  other  brushed 
over  the  affected  parts;  and  G.  H.  Fox  has  reported 
improvement  in  some  cases  treated  with  static  elec- 
tricity. H}iDodermic  injections  of  i  to  yV  grain  of 
the  muriate  of  pilocarpin  every  few  days  are  well 
spoken  of  by  some  observers. 

Sulphur  ointment  is  advocated  by  Thin  {^Ih'S),  and 
he  has  published  a  series  of  excellent  results  from  this 
treatment,  maintaining  that  these  results  are  due  to 
the  action  of  the  ointment  as  a  parasiticide. 

The  treatment  by  blistering  has  in  some  cases  pro- 
duced rapid  results.  For  this  purpose  either  croton- 
oil  or  cantharides  may  be  used.  Thus,  Horand  (21  S) 
advises  painting  the  bald  spots  with  croton-oil,  cov- 
ering with  cotton,  and  wearing  a  hood  over  all.  If 
ulceration  is  caused,  the  part  is  to  be  dressed  with 
oHve-oil.  When  healed,  the  application  of  the  croton- 
oil  is  to  be  repeated.  This  method  of  ti'eatment  is  to 
be  continued  till  the  hair  grows.     Vidal  (2G6)  recom- 


ALOPECIA    AREATA.  133 

mends  the  following:  If  the  subject  is  a  child,  the 
whole  head  is  to  be  shaved.  If  the  patient  is  older, 
the  scalp  is  to  be  shaved  for  half  an  inch  around  the 
bald  spot.  Now  apply  a  bhster,  which  should  never 
be  larger  than  a  twenty-five  cent  piece,  to  each  bald 
area,  putting  it  on  in  the  morning  and  taking  it  off 
when  the  epidermis  begins  to  rise.  If  a  large  bleb 
forms,  it  should  be  opened.  Powder  the  blisters  with 
starch  and  cover  with  linen.  If  there  are  numerous 
bald  spots,  apply  the  blisters  to  them  successively. 
If  the  hair  does  not  grow  after  thorough  bhstering, 
repeat  the  operation  as  soon  as  the  effects  of  the  first 
application  have  disappeared.  If  blisters  are  not  well 
borne,  use  sinapisms.  When  the  hair  begins  to  gi'ow, 
shave,  and  rub  in,  every  morning  and  evening,  a  lo- 
tion of 


Liq.  ammon.       .         .         .         . 

3 

Alcohol, 

.       12, 

Decoct,  foliae  juglandis,     . 

.      LOO, 

M. 

For  alopecia  areata  of  the  face  he  uses  bhsters  in  some 
cases.  Generally  he  has  the  part  shaved  every  day 
and  uses  frictions  of  tincture  of  cantharides,  either 
pure  or  with  one-fifth  to  one-sixth  of  the  tincture  of 
rosemary. 

CouRREGES  (53),  a  believer  in  the  parasitic  origin  of 
this  disease,  directs  that  the  head  be  washed  twice  a 
day  with  a  lotion  of 

Chloride  of  ammonia 

Bichloride  of  mercury,  .         .  aa        1. 

Water, 500. 

M. 
or  that  the  following  ointment  be  applied  twice  a  day; 

Yellow  sulphate  of  mercury,  .  1. 

Lard, 30. 

M. 


1C.4  DISEASES   OF  THE   HAIR  AND   SCALP. 

This  lie  does  to  destroy  the  parasite.  To  stimulate  the 
gi*o^^i:h  of  the  hair  he  advises  shaving  once  or  twice 
a  week.  If  there  is  only  one  patch  or  but  two  or 
tln*ee,  these  and  their  inunediate  neighborhood  are  to 
be  shaved.  Should  there  be  many  patches,  the  whole 
scalp  is  to  be  gone  over  with  the  razor. 

Cottle  (52)  du*ects  that  the  affected  area  be  painted 
with  acetic  acid  until  the  scalp  whitens,  and  then 
sponged  off  with  cold  water.  This  is  to  be  repeated 
every  three  or  foiu'  days;  and  in  the  inteiwals  an  oint- 
ment composed  of  three  drachms  of  balsam  of  Peru  in 
one  ounce  of  benzoated  lard  is  to  be  apphed. 

GuiBOUT  (14)  recommends  shading,  fiictions  T\'ith 
camphorated  alcohol,  and  bathing  very  often  during 
the  day  with  equal  parts  of  camphor  and  sulphm-ous 
ether. 

A.E.  EoBixsox  (33)  speaks  favorably  of  inunctions 
with  a  five  to  ten  per-centum  ointment  of  clirysarohin 
preceded  by  vigorous  friction  with  soap  and  water 
and  a  rough  towel.  He  later,  1SS7,  recommends  equal 
parts  of  croton  oil  and  any  other  oil,  reducing  the 
strength  if  too  much  reaction. 

Lassar  reports  satisfactory  effects  in  two  cases  from 
the  use  of  corrosive  sublimate  lotions,  followed  by  dis- 
infectant oils  such  as  salicylated  or  carbolised  oil.  In 
some  cases  of  alopecia  areata  I  have  used  a  solution 
of  corrosive  sublimate,  not  on  account  of  its  parasiti- 
cide qualities,  but  solely  for  its  stimulating  effect. 
The  strength  of  the  solution  used  was  three  parts  of 
the  bichloride  of  mercury  in  one  thousand  parts  of 
water,  or  say  one  grain  and  a  half  to  the  ounce.  This 
was  apphed  once  or  twice  a  day,  and  has  given  satis- 
factory results.  One  patient,  a  man  aged  thirty  years, 
had  upon  his  head  a  number  of  perfectly  bald  patches 
of  alopecia  areata,  some  of  which  had  lasted  for  more 
than  a  year.  He  was  given  the  bichloride  lotion  just 
indicated.    In  fourteen  days  lanugo  hairs  had  begun 


ALOPECIA   AREATA.  135 

to  grow  in  all  the  patches,  and  in  three  months  they 
were  completely  covered  with  vigorous  though  white 
hairs.  He  had  used  the  lotion  alone  and  shaved  the 
patches  once  in  two  weeks  after  the  hair  had  begun 
to  grow.  Unfortunately,  this  is  the  only  case  in 
which  I  have  been  able  to  watch  the  effect  of  this 

treatment. 

In  a  few  cases  I  think  that  I  have  produced  benefit 
by  using  a  pomade  of  jaborandi,  made  by  boiling  down 
the  fluid  extract  to  one  half  its  volume  and  adding 
this  to  lard  in  the  proportion  of  one  of  the  jaborandi 
to  four  of  the  lard.  This  is  to  be  thoroughly  rubbed 
in  twice  a  day.  In  the  first  case,  of  the  recurrent  type, 
the  hair  in  two  relapses  returned  under  this  treatment 
in  the  course  of  ten  weeks.  But  it  had  no  effect  in 
preventing  the  formation  of  new  patches.  In  the 
second  case,  occurring  in  a  child  with  chorea,  after  the 
use  of  various  other  remedies  for  three  months,  the 
spots  continually  growing  larger,  the  jaborandi  was 
used,  and  in  ten  weeks  the  disease  had  ceased  spread- 
ing, and  the  hair  was  growing  on  every  patch.  In  a 
third  case,  affecting  the  mustache  of  a  medical  student, 
its  use  was  followed  in  seven  weeks  by  the  appearance 
of  new  hairs  in  the  patch,  shaving  being  practiced  at 
the  same  time.  In  these  three  cases,  the  return  of 
the  hair  took  place  some  six  or  seven  months  after 
the  beginning  of  the  disease.  Pilocarpine  may  be 
substituted  for  the  jaborandi  in  the  strength  of  two 
or  three  grains  to  the  ounce.  Lanolin  is  a  good  ex- 
cipient  for  it,  as  it  penetrates  the  skin  more  readily 
than  lard.  It  should  be  diluted  with  one  or  two 
drachms  of  castor-oil  to  the  ounce  to  make  it  more 
fluid,  and  the  whole  may  be  jjerfumed  with  one  or 
two  drops  of  oil  of  roses. 

MiCHELSON  (40),  in  Ziemssen's  Handhuch  (vol.  II.  pg. 
\?>\)),  speaks  highly  of  the  use  of  warm  salt-water  baths 


136  DISEASES   OF  THE   HAIR  AND   SCALP. 

five  per  cent,  salt)  three  times  a  week  and  of  twenty- 
five  minutes  duration.  In  conjunction  with  this,  twice 
a  week  the  faradic  current  is  to  be  apphed  to  the  scalp 
with  a  brush  electrode  for  ten  minutes.  Upon  the 
days  when  the  baths  are  not  used,  the  scalp  is  to  be 
rubbed  with  a  stronger  aqueous  solution  of  salt. 

Chatelaix  (102  ap.)  advises  painting  the  patches,  as 
well  as  for  a  short  distance  beyond  their  borders,  with 
iodine  one  part,  collodion  thirty  parts.  This  is  to  be 
renewed  when  it  falls  off.  After  a  few  applications 
the  pellicle  is  to  be  pulled  off,  and  with  it  the  fine  new 
hairs.  If  it  causes  a  good  deal  of  dermatitis,  it  may 
have  to  be  stopped  for  a  while.  The  rest  of  the  hair  is 
to  be  treated  with  an  antiseptic  solution. 

MoTY  (201  ap.)  expects  rapid  results  from  injecting 
five  or  six  drops  of  a  solution  composed  of 

Ijt  Hydrarg.  bichlor.,  .  ...  4 
Cocain.  hydrochlor.,  ....  2 
Aquae  destillat., 100 

M. 

In  a  small  patch  only  one  injection  is  made;  in 
larger  patches  four  or  five  injections  are  made  about 
the  periphery.  Intervals  of  four  or  five  days  should 
1)6  made  between  the  injections.  He  finds  that  the 
hair  will  begin  to  grow  in  about  three  weeks. 

QuiNQUAUD  (212  ap.)  recommends  washing  the 
patches  in  the  morning  ^vith  soap  and  water,  and  ap- 
plying 

5  Hydrarg.  biniod., 20 

''        bichlorid.,    .         .         .         .1. 

Alcohol, 40. 

Aqua3,  ..••...  250. 
M. 


ALOPECIA  AREATA.  137 

At  night  the  parts  are  to  be  washed  again,  and  then  a 
solution  of  six  per  cent,  of  Hq.  ammon.  in  equal  parts 
of  balsam  of  Fioraventi  and  spirits  of  camphor.  Af- 
ter eight  days  substitute  tincture  of  pyrethrum  for 
the  ammonia,  and  so  alternate  every  eight  days. 
Every  sixth  day  the  following  ointment  is  to  be  used  : 

5  Chrysarobin, 

Ac.  salicyl., 
"  boric,  .        •        .        .     aa      2 

Vasehni, 100 

M. 

KA.YMOND  (213  ap.)  saw  recovery  take  place  in  four 
months  by  Moty's  treatment,  the  hair  coming  in  of 
normal  color,  and  recovery  beginning  often  at  the  pe- 
riphery. Sometimes  the  method  is  very  painful,  but 
tolerance  seems  to  be  established  after  a  time.  He 
has  seen  one  case  recover  after  seven  injections  of 
pure  water.  He  thinks  the  application  of  Bidet's 
vesicating  liquid  gives  as  good  results  as  Moty's 
method.  He  has  seen  recovery  take  place  in  thirty  to 
forty  days  after  using  Quinquaud's  method.  He  him- 
self recommends  shaving  the  periphery  of  the  patch 
and  washing  its  surface  with  carbolic  soap  twice  a 
week.    Every  morning  the  following  wash  : 


IJ  Hydrarg.  bichlor., 

. 

.50 

Tinct.  cantharidis, 

. 

.     25. 

Balsam  of  Fioraventi, 

, 

.     50. 

Aq.  Cologniensis, 

. 

.   150. 

M. 

is  to  be  applied  to  the  whole  head  and  rubbed  into  the 
patches  with  a  paint  brush  for  one  or  two  minutes. 
In  the  evening  the  spots  are  to  be  rubbed  with  a  mix- 
ture composed  of 


138  DISEASES  OF  THE   HAIR  AND   SCALP. 

5  Ac.  salicyl., 2 

^  uaphthol, 10 

Ac.  acetic,  crystal  ,          ....  15 

01.  riciui, 100 

M. 

This  treatment  should  cause  only  redness  and  should 
cure  in  fifty  days,  the  hair  often  coming  in  normal. 

BusQUET  (^161  ap.)  speaks  enthusiastically  of  the 
treatment  by  33^  per  cent,  of  essence  of  cinnamon  or 
spikenard  in  ether.  Others  have  tried  it  with  no 
benefit. 

Morel-Lavellee  (193  ap.)  recommends  superficial 
scarifications  of  the  patches  before  the  application  of 
an  antiseptic  ointment,  and  expects  return  of  the  hair 
after  the  third  scarification. 

Morrow  (200  ap.)  advises  appl3dng  to  recent  patches 
either  chrysarobin  eight  to  ten  per  cent.,  or  salicylic 
acid  two  to  five  per  cent.,  every  three  or  four  days. 
In  more  severe  cases  equal  parts  of  acetic  acid  and 
chloroform  are  to  be  used  two  or  three  times  a  week  at 
first,  and  later  at  longer  intervals.  Between  the  ap- 
phcations  of  any  of  the  foregoing  this  mixture  ; 

^  01.  eucalypti, 

01.  terebinthinae,        .  aa  3ss.,  say   15 

01.  petrolei  crud., 

Alcohol,       .        .        .        .  aa3  j.,  say    35 
M. 

is  to  be  used  d?*V  with  massage  for  about  five  min- 
utes. 

BuLKLEY  (160  ap.)  advises  the  application  of  pure 
carboUc  acid  to  small  portions  of  large  patches  at  a 
sitting.  Cutler  (166  ap.)  recommends  equal  parts  of 
carbohc  acid,  chloral,  and  iodine  painted  on  the  parts 
every  few  dc'^s.  This  has  given  good  results  in  my 
hands. 


ALOPECIA  AREATA.  139 

As  alopecia  areata  has  a  tendency  to  get  well  of  it- 
self, n,'  It'^  own  good  time,  it  is  hard  to  determine  how 
far  our  remedies  are  active  in  hastening  a  cure.  So 
good  an  authority  as  Kaposi  (19)  has  said  that  reme- 
dies have  httle  if  any  effect  on  the  disease. 

Even  after  the  damage  to  the  hair  has  apparently 
been  made  good,  it  is  advisable  to  counsel  our  patients 
to  use  some  mildly  stimulating  lotion  to  the  scalp,  and 
to  pay  particular  attention  to  the  hygiene  of  the  hair 
for  some  months. 


CHAPTER  YIII. 

ATROPHIA   PILORUM   PROPRIA. 

Atrophy  of  the  hair  exists  under  three  forms, 
namely:  FragiUtas  crinium,  Trichorrhexis  nodosa,  and 
Aplasia  pilorum  propria.  In  all  the  hair-shaft  is  easily- 
friable  and  splits,  or  breaks  off  of  itself  or  upon  the 
sUghtest  traction.  The  three  forms  differ,  in  that  in 
the  first  there  is  only  a  simple  or  compound  cleavage 
of  the  hair;  in  the  second,  there  is  also  the  formation 
of  nodular  swellings  along  the  hair-shaft,  and  a  brush 
like  breaking  up  of  the  elements  of  the  hair;  while  in 
the  third,  the  fracture  occurs  through  the  internodu- 
lar  portion. 

Fragilitas  CRmiUM. 

Synonyms  : — Scissura  pilorum. — Trichoptilosis. — Tri- 
choxerosis. 

Definition. — That  condition  of  the  hair  in  which  it 
is  more  or  less  dry,  and  its  shaft  is  split  either  at  its 
end  or  in  its  continuity.  It  may  be  symptomatic  or 
idiopathic. 

1.  Symptomatic  Fragilitas  Crinium^— This  form  is 
by  far  the  most  common  variety  of  the  disease,  and 
needs  little  comment  here.  In  the  parasitic  diseases  of 
the  hair — trichophytosis  capitis  et  barbse,  and  favus — 
the  hair  becomes  dry,  brittle,  and  broken  off.  This  con- 
dition of  the  hair  is  always  met  with  in  these  diseases 
and  is  a  diagnostic  symptom.  In  any  disease  of  the 
scalp  if  of  long  continuance  we  meet  with  dryness  and 
brittleness  of  the  hair,  and  this  is  notably  the  case  in 
seborrhoea  sicca  and  eczema.  In  any  general  consti- 
tutional disease,  as  in  fevers,  phthisis,  scrofula,  and 
the  various  cachexiae,  in  which  there  is  a  lowering  of 


ATROPHIA    PILORUM    PROPRIA.  141 

the  nutrition  of  the  body,  the  hair  sympathizes,  loses 
its  lustre  and  suppleness,  and  takes  on  the  condition 
of  fragilitas  crinium. 

Etiology. — The  causes  of  this  condition  are  easily 
discoverable.  In  the  parasitic  diseases,  the  fungus 
grows  in  and  about  the  hair  and  its  root,  and  by  its 
presence  causes  a  degeneration  of  the  hair.  In  favus, 
a  complete  destruction  of  the  hair-follicle  and  papilla 
takes  place.  In  seborrhoea  and  eczema  the  hair  be- 
comes dry,  because  it  is  deprived  of  its  proper  lubricant, 
on  account  of  alterations  in  the  sebaceous  matter,  and 
because  its  nutrition  is  interfered  with.  In  the  gen- 
eral constitutional  diseases,  mal-nutrition  is  the  cause 
of  the  fragility  of  the  hair. 

Treatment. — This  will  depend  upon  the  disease 
which  the  condition  accompanies,  and  will  be  given 
in  the  proper  chapters. 

2.  Idiopathic  Fragilitas  Crinium. — In  this  form, 
without  any  apparent  disease  of  the  scalp  or  underly- 
ing skin,  and  often  without  any  general  constitutional 
disease,  the  hair  becomes  dry,  brittle  and  split.  The 
cleft  in  the  hair  may  be  either  at  its  free  end,  in  the 
continuity  of  the  shaft, or  even  within  the  bulb.  When 
beginning  at  the  free  extremity,  it  may  run  for  some 
distance  up  the  shaft.  When  it  begins  at  the  exit 
fi'om  the  follicle,  the  cleft  extends  for  a  variable  dis- 
tance, it  may  be  for  the  whole  length  of  the  shaft.  In 
this  case  and  in  the  case  in  which  the  cleft  occurs  in 
the  middle  of  the  shaft,  the  filaments  will  either  sepa- 
rate widely  or  hold  together.  When  the  split  occurs 
at  the  end,  the  filaments  will  either  separate  from 
each  other  more  or  less,  or  will  curl  up  upon  them- 
selves. The  disease  occurs  most  often  upon  tiie 
scalp,  the  beard  being  the  part  next  most  frequently 
affected.  It  is  by  far  most  commonly  met  with  in 
the  long  hair  of  women.      The    affected    hairs    are 


U2 


DISEASES  OF  THE  HAIR  AND  SCALP. 


scattered    here 


y 


■.'\ 


5p 


Pi 


?ftr  if 


Splitting:  of  the  end 
of  a  hair.  T.n,  Trichor- 
rhexis nodosa.  S.p, 
Scissu  ra  piloruni. 
(Michelson.) 


and  there  throughout  the  general 
mass  of  hair,  wliich  may  appear  nor- 
mal or  be  somewhat  drier  than  it 
should  be.  In  some  cases  all  the  hair 
of  a  certain  portion  of  the  scalp  is 
found  broken  up  into  filaments.  Be- 
sides the  splitting,  the  affected  hairs 
may  show  no  other  abnormality,  al- 
though they  are  often  irregular  and 
uneven  in  their  contour. 

In  a  case  reported  by  Duhring  (280), 
which  is  unique,  the  beard  was  the 
region  affected.  In  it  the  hak  began 
to  split  within  the  bulb,  and  the  pro- 
cess was  attended  by  so  great  an  irrita- 
tion of  the  f oUicles  as  to  cause  follicular 
papules  and  pustules.  '^The  hairs," 
he  says,  "were  very  bristly;  sometimes 
they  were  of  good  length,  sometimes 
short,  sometimes  thicker  than  normal, 
sometimes  abnormally  slender,  some- 
times straight,  sometimes  crooked. 
Sometimes  they  came  out  easily  when 
pulled  upon,  or  fell  out  of  themselves, 
and  sometimes  they  were  quite  fast  in 
the  follicle  and  broke  off,  leaving  the 
root  behind,  when  epilation  was  at- 
tempted.'' 

Pathology.  —  In  most  cases  the 
microscopical  examination  shows  noth- 
ing of  importance,  ai)art  from  a  lit- 
tle irregularity  in  the  contour  of 
the  shaft,  and  the  split  at  the  end 
with  its  diverging  filaments.  The 
bulb  of  the  hair  may  be  normal  or 
atrophied.      In  Duhring's  (280)  case, 


ATROPHIA    PILORUM    PROPRIA.  143 

there  were  marked  atrophy  of  the  hair-bulbs  and 
fissure  of  the  hair-shaft  beginning  within  the  bulb, 
separation  of  the  segments  taking  place  at  the 
bulb  or  at  varying  distances  beyond  it.  The  corti- 
cal substance  presented  a  dry  and  brittle  look  in  the 
narrowed  portions,  and  a  spongy  luxuriant  appearance 
in  the  thickened  parts  of  the  hair.  The  medulla  was  no- 
where normal,  but  was  present  here  and  there  in 
broken  tracts. 

Etiology. — The  cause  of  this  disease  is  yet  undeter- 
mined. Kaposi  (19)  would  explain  the  splitting  of  the 
long  hair  of  women  upon  the  theory  that  it  is  due  to 
the  distance  of  the  distal  extremity  of  the  hair  from  its 
source  of  nourishment — the  hair-root  or  papilla.  Tliis 
is  not  an  altogether  satisfactory  explanation,  as  it  is  by 
no  means  always  the  longest  hairs  which  present  the 
cleft  end.  Nor  would  this  theory  account  for  the 
disease  as  met  with  in  the  short  hairs  of  the  beard. 
Gamberini  (59)  would  find  its  cause  in  want  of  due  care 
of  the  hair  and  in  allowing  it  to  grow  to  excess.  But 
as  in  the  symptomatic  form,  there  is  some  evident  dis- 
ease affecting  the  nutrition  of  the  hair,  and  as  in  some 
of  the  idiopathic  cases,  there  is  an  atrophy  of  the  bulb; 
we  can  feel  sure  that  the  idiopathic  form  also  is  depend- 
ent upon  some  interference  with  the  nutrition  of  the 
hair. 

Treatment. — In  all  cases  the  scalp  or  underlying 
skin  should  be  kept  in  good  condition,  as  is  directed 
in  Chapter  III.  When  the  disease  occurs  in  tlie 
long  hair  of  women,  besides  attention  to  the  scalp 
and  the  brushing  and  combing  of  the  hair,  the  cleft 
ends  should  be  carefully  cut  off  just  above  the 
split.  If  the  disease  occur  in  the  beard  it  should 
likewise  be  regularly  clipped,  and  all  rough  rubbing 
and  handling  of  it  should  be  avoided.  In  shaving,  we 
have  a  last  resort  by  which  the  deformity  may  be 


144  DISEASES   OF  THE   HAIR  AND  SCALP. 

removed,  and  possibly  after  a  time  the  hair  may  grow 
normally:  but  this  should  be  ordei^ed  only  in  very 
aggravated  cases  in  women,  as  it  is  an  heroic  plan  of 
treatment  for  them,  and  milder  measures  will  gener- 
ally be  sufficient.  In  all  cases  we  should  strive  to  cor- 
rect any  thing  that  we  find  wrong  in  the  health  and 
well-being  of  the  patient. 

Trichorrhexis  Nodosa. 

Synonyms: — Trichoclasia  ;  Trichoptylose  ;  Clasto- 
thrix;  Trichosyphilis;  Nodositas  crinium. 

Definition. — Trichorrhexis  nodosa  is  that  condition 
of  the  hair  in  which  nodular  swellings  occur  along  its 
shaft  and  the  hair  breaks  easily,  usually  through  one 
of  the  nodes,  and  exhibits  a  peculiar  brush-like  spread- 
ing out  of  the  fibres  of  the  broken-off  hair,  while  the 
underlying  tissues  are  normal. 

This  disease  was  first  described  by  Beigel  (276)  in 
1855,  under  the  title  ^' Auftreibung  und  Bersten  der 
Haare."  Wilks  (309)  recognized  the  disease  in  1852, 
but  did  not  publish  an  account  of  it  until  1857.  Wil- 
son (311)  asserts  that  he  described  it  in  1849  in  his 
book,  ^^ Healthy  Skin,"  under  the  title  of  ''fragilitas 
crinium,"  and  proposed  the  name  of  ' ' clastothrix  "  for 
it.  In  1867  he  exhibited  to  the  Eoyal  Medical  and 
Chirurgical  Society  of  London,  specimens  of  what  he 
called  trichosyphilis  of  the  beard  and  whiskers,  which 
he  considered  as  a  disease  distinct  from  fragilitas 
crinium.  This  was  probably  a  case  of  trichorrhexis 
nodosa.  Eichhorst  (281)  reported  a  case  in  1858;  since 
then  various  authorities  have  met  with  the  disease 
and  published  cases  of  it.  Kaposi  was  the  first  to 
propose  for  it  the  name  of  ''  trichorexis  nodosa,"  which 
has  been  accepted  by  the  profession  as  the  proper 
name  for  the  disease.  The  spelling,  however,  has  been 
slightly  changed,  and  it  is  now  spelt  either  as  '^tricho- 


ATROPHIA   PILORUM  PROPRIA.  145 

rhexis"  or  "trichorrhexis."  Wo  have  adopted  the 
latter  style,  as  it  is  the  one  used  by  the  best  wi-iters  of 
the  German  school.  The  disease  is  rare.  Bulkley 
met  with  it  but  four  times  in  eight  thousand  cases. 

Symptoms. — The  disease  comes  on  without  any  ante- 
cedent symptoms,  the  patient  first  noticing  upon 
handling  his  beard  that  the  hairs  when  pulled  through 
his  fingers,  feel  irregular  and  knotty,  or  else  that  the 
hair  breaks  easily  and  the  beard  looks  ragged.  If  we 
examine  the  beard  we  find,  along  the  hair-shaft,  one  or 
more  whitish  or  grayish,  shiny,  transparent,  nodular 
swelhngs,  looking  not  unlike  the  nits  of  pediculi,  but 
more  oval^and  evenly  involving  the  whole  circumfer- 
ence of  the  hair.  Should  the  hair  be  red,  the  color  of 
the  nodes  may  be  black.  The  number  of  nodes  upon 
a  single  hair  varies  from  one  to  five,  and  their  diameter 
varies  with  that  of  the  hair,  being  greater  in  the  coarser 
than  the  finer  hair.  The  nodes  occur  nearer  the  distal 
than  the  proximal  end  of  the  hair,  and  usually  in  the 
upper  third  of  its  length.  The  hair  is  exceedingly 
brittle  and  fractures  upon  shght  traction,  as  on  comb- 
ing, or  spontaneously,  the  fracture  taking  place  almost 
invariably  through  a  node,  and  the  hair  fibres  of  the 
broken  ends  separating  like  the  hairs  of  a  paint  bmsh. 
Very  rarely  the  fracture  is  internodular  and  the  ends 
pointed.  Sometimes  the  hair  does  not  entirely  break 
off,  but  the  fibres  splinter  about  the  node,  and  the 
appearance  presented  is  like  that  seen  when  two  small 
paint  brushes  are  pushed  together,  end  to  end.  The 
fracture  is  usually  transverse  through  the  node,  but 
sometimes,  if  there  is  an  excessive  amount  of  medulla 
present,  it  is  longitudinal. 

Sometimes  the  hair -has  an  irregular  contour  and  is 
frayed  along  its  entire  length.  When  many  hairs  are 
affected,  there  will  always  l)e  many  frayed-out  ends, 
and  the  beard  will  look  as  if  it  had  been  singed.     The 


146  DISEASES   OF   THE   HAIR   AXD   SCALP. 

liairs  are  usually  firmly  fixed  in  the  follicles,  and  the 
disease  exists  for  many  years  with  no  tendency  to  the 
production  of  alopecia. 

The  disease,  in  nearly  all  the  reported  cases,  affected 
the  beard,  and  therefore  occurred  in  men;  but  it  does 
occur  at  times  in  the  scalp-hair  and  also  in  women. 
Tlius  W.  G.  Smith  (303)  reported  a  case  which  occurred 
in  the  scalp- hair  and  was  pecuHar  in  that  the  fracture 
took  place  in  the  internodular  portions,  and  the  ends 
of  the  broken  hairs  were  not  frayed  out.  There  was 
also  one  nodose  hair  found  amongst  the  pubic  hair. 
MiCHELSOX  (40)  beheves  that  the  condition  is  far  more 
frequent  in  the  scalp -hair  than  is  supposed,  and  that 
the  reason  it  is  most  frequently  observed  in  the  beard 
is  because  the  hairs  of  that  paii  are  of  larger  diameter, 
and  allow  the  condition  to  be  more  readily  seen.  On 
thin  hairs  the  little  nodes  can  be  more  easily  felt  than 
seen,  indeed  they  can  be  hardly  distinguished  by  the 
naked  eye.  He  has  met  with  the  disease  many  times 
in  cases  of  various  forms  of  alopecia.  Detergie  (279) 
has  also  reported  a  case  that  occurred  in  the  scalp-hair 
of  a  woman.  Abramow^tsch  (230  ap.)  reports  a  case 
affecting  the  scalp-hair  of  a  man.  I  have  met  with 
two  cases  in  w^omen,  both  of  whom  came  to  me  on 
account  of  their  hair  being  short.  They  were  both 
debilitated.  The  disease  has  been  seen  on  the  axillary 
hairs  and  those  of  the  eyebrow^s. 

Etiology. — The  cause  of  the  disease  is  obscure. 
Beigel  (270)  believed  that  it  was  due  to  an  accumula- 
tion of  gas  within  the  substance  of  the  hair,  which, 
exercising  pressure  from  within,  first  gave  rise  to  the 
bulbous-formed  swelling,  and  ultimately  burst  the 
hair.  Wilks  (310)  and  Wilson  (211)  look  to  nutritive 
debility  for  an  explanation  of  the  malady.  Eich- 
horst's  (281)*  theory  is,  that  the  swellings  are  caused 
by  fatty  infiltration  of  the  medulla,  taking  place  at 
certain  points,  and  that  the  splitting  is  purely  acciden- 


ATROPHIA    PILORUM    PROPRIA.  147 

tal,  the  result  of  pulling,  in  brushing  and  combing  the 
hair.  He  thinks  it  probable  that  a  swelhng  of  the 
medulla  first  ojccurs  that  causes  a  bulging  outwards  of 
the  cortical  substance  till  it  finally  bursts  and  breaks 
asunder. 

So  much  for  the  earlier  theories.  Of  more  recent 
date  are  those  of  Schwinimer,  Startin,  Pye-Smith, 
Kohn,  Pincus,  Wolfberg  and  Michelson.  Schwimmer 
(301)  says  that  the  disease  is  a  nutritive  disturbance, 
probably  a  tropho-neurosis.  Startin  (305)  holds  that 
it  is  due  to  a  degeneration  of  the  medulla,  a  consequent 
rapid  accumulation  of  ceUs  at  one  point,  and  eventually 
a  bursting  open  of  the  hair. 

Pye-Smith  (289)  regards  a  gradual  drying  of  the  cor- 
tical substance,  and  a  consequent  loss  of  coherence  of 
its  constituent  fibre  cells,  as  the  cause;  this  being  fol- 
lowed or  attended  by  the  breaking  up  into  a  granular 
material  and  sweUing  of  the  ceUs  of  the  nieduUa,  and 
finally  a  rupture  of  the  cortex,  there  being  nothing 
left  to  hold  it  together.  S.  Kohn  (2SG)  beheves  that 
the  process  is  analogous  to  the  splitting  of  the  long 
hair  in  women,  and  is  to  be  considered  as  an  atrophy 
of  the  medulla  taking  place  at  different  points,  or  as 
a  partial  disappearance  of  the  same.  Pincus  (2D6) 
regards  the  disease  as  in  part  due  to  an  interference 
with  the  nutrition  of  the  hair  and  in  part  to  a  deficient 
action  of  the  sebaceous  glands.  Wolfberg  (312)  puts 
forth  the  view  that  repeated  mishandling  of  the  thick 
medullated  hairs  of  the  beard,  as  in  violent  lubbing 
in  drying  after  washing,  is  sufiicient  to  cause  the  dis- 
ease in  many  people,  and  in  this  way  he  has  designedly 
produced  appearances  microscopically  identical  with 
those  of  trichorrhexis  nodosa.  He  believes  this  to  be 
the  only  cause  of  the  disease,  and  gives  the  following 
four  reasons:  1.  The  anatomical  appearances.  The 
hair  outside  of  the  nodes  is  perfectly  normal.  The 
same  appearances  can  be  produced  mechanically,  and 


us  DISEASES   OF   THE   HAIU   AND   SCALP. 

tlie  disease  occui*s  often  in  diseases  of  the  beard  which 
are  itchy  and  hence   cause  it  to  be  much  rubbed. 

2.  Location.  It  occurs  most  always  in  the  strong 
medullated  hair  of  the  beard,  the  node  formation  being 
favored  by  the  central  canal.  These  appearances  are 
difficult  of  production  in  fine  non-medullated  hairs. 

3.  Because  the  explanations  heretofore  offered  are 
not  sufficient,  -i.  The  obstinacy  of  the  disease  to 
treatment.  This  is  easily  explained,  because  it  has 
consisted  in  rubbing  the  beard  with  irritating  sub- 
stances. Sherwell  (302),  in  his  case,  suspected  a  some- 
what similar  cause  on  accoiuit  of  his  patient's  habit  of 
rubbing  cologne  water  into  his  beard;  but  subsequently 
he  abandoned  the  theory.  Michelsox  (40)  looks  upon 
abnormal  dryness  of  the  hair-shaft  as  the  cause. 

AVe  have  thus  ten  different  views  expressed  in  re- 
gard to  the  cause  of  tliis  singular  affection.  To  choose 
any  one  as  the  true  cause,  would  be  un\\'ise  at  present. 
The  disease  is  not  parasitic.  Tliis  I  beheve  is  the  unan- 
imous testimony.  Cheadle  and  Morris  (278)  have, 
it  is  true,  reported  a  case  to  which  they  gave  the  name, 
amongst  others,  of  trichorrhexis  nodosa,  but  it  was  so 
different  in  its  appearances  from  the  disease  in  ques- 
tion, that  we  should  rather  call  it  "  tinea  nodosa.''  It 
does  not  seem  to  depend  upon  any  diathesis,  nervous 
or  otherwise.  Axdersox  (274)  has  reported  one  case 
or  other^\ise.  Newtox  (211  ap.),  who  studied  the  dis- 
ease in  two  cases,  is  convinced  that  it  is  a  pure  neu- 
rosis. Anderson  (274)  has  reported  one  case  which 
shows  an  hereditary  inffiience.  The  disease  in  his  case 
was  congenital,  or  d early  so,  and  could  be  traced  back 
as  far  as  the  great-grandmother.  Those  members  of 
the  family  who  had  what  they  called  ^'weak  hair," 
were  almost  invariably  of  dark  complexion.  He  gives 
the  following  "family  tree,'' those  marked  with  an 
asterisk  ("••)  having  ^'weak  hair.''  (By  this  term  is 
apparently  meant  hair  that  sphts  easily.) 


lTrophia  pilorum  propria.  140 

Mr.  L.     Mrs.  L.* 


Mrs.  B.* 


Robert,  James,  John,*  David,         William,  Thomas,*  Samuel. 


Marion,  James,*  Jane,*  John,    John,  William,  James,*  Thomas, 

Mary,*  Margaret,*  Thomas.*  |  William.* 


Thomas,  James,*  Walter,  Margaret.*  Mabel,*  Maud. 

I  have  met  with  but  two  cases  of  the  disease.  Both 
occurred  in  men  and  in  the  beard;  and  both  patients 
were  in  the  habit  of  handUng  the  beard.  As  far  as 
these  cases  are  concerned  I  would  be  incUned  to 
adopt  Wolfberg's  theory.  The  fracture  of  the  hair  is 
probably  always  due  to  mechanical  causes. 

Pathology.— Beigel  (276),  who  first  described  the 
disease,  found  minute  globular  bodies  in  the  shaft  of  the 
hair  which  he  took  to  be  air-globules.  Wilson  (311), 
in  his  case  of  syphilitic  degeneration  of  the  hair,  which 
was  probably  a  case  of  the  disease  we  are  now  discuss- 
ing, observed  "the  diseased  portions  of  the  hair  look- 
ing as  if  composed  of  a  dark  cylinder  enclosed  in  a 
transparent  envelope.  Closer  examination  showed 
that  the  fibrous  structure  of  the  hair  was  lost,  and 
its  place  occupied  by  a  dark  gummous-looking  sub- 
stance. The  essential  peculiarity  of  structure  of  the 
diseased  hair  was  arrest  of  development  of  the  fibrous 
portion  at  its  cellular  stage,  the  dark  cylinder  which 
formed  the  bulk  of  the  diseased  part  being  compose( . 
of  large  and  small  nucleated  cells  commingled  with 
pigment  matter,  irregularly  formed  air-cells  and  frag- 
ments of  crystaline  substance."  Eichhorst  (281)  saw 
"in  hairs  which  were  examined  dry  or  in  glycerine, 
that  the  individual  fibres  of  the  cleft  hair  were  in 
places  covered  with  fine  ghstening  kernels.  As  these 
were  not  seen  in  preparations  in  Canada  balsam  and 
in  turpentine,  and  as  they  were  colored  very  black  by 


150  DISEASES   OF   THE   HAIR   AND   SCALP. 

hyi^er-osmic  acid,  they  were  doubtless  fat  drops.  The 
further  the  sweUing  had  proceeded,  the  less  were  they 
seeu.  The  nodes  were  exclusively  on  the  medulla,  the 
cells  of  which  could  be  traced  into  the  spindle-formed 
broken-up  nodes,  and  appeared  unaltered.  But  when 
hquor  potassae  and  hyper- osmic  acid  were  used,  the 
medulla  cells  were  seen  to  be  overladened  with  drops  and 
masses  of  fat. ' '  Wilks  found,  interspersed  in  the  broken 
fibres,  a  few  dark  granules.  Such  were  the  findings  of 
the  earher  investigators.  Now  let  us  turn  to  the  more 
recent  investigations  and  see  what  they  teach  us. 
Pye-Smith  (29S),  in  1879,  reported  upon  certain  speci- 
mens of  the  disease  as  follows:  ''Fust  stage;  hair 
swollen  in  fusiform  nodules  at  inteiwals  of  a  few  lines. 
Later,  the  cortical  layer  has  begun  to  spht  up  and  to 
separate  transversely.  In  the  more  advanced  cases  a 
fine,  granular  material  oozes  out  from  the  medullary 
portion.  Lastly  the  hair  breaks  across  leaving  the 
brush-like  broken  end  formed  by  the  frayed-out  cor- 
tical fibres.  Under  a  high  power  the  exuded  material 
appears  as  a  uniform,  finely  granular  substance.  This 
has  some  resemblance  to  fish  roe  and  might  be  mis- 
taken for  sporules.  There  is  no  vegetable  substance 
present.  It  is  not  probable  that  a  development  of  gas 
causes  the  hair  to  spht.  Apparently  the  cortex  be- 
comes more  and  more  dry,  its  constituent  fibre-ceUs 
become  less  coherent,  tlie  medulla  cells  l)reak  up  into 
this  gi-anular  material  and  swell,  till  the  rupture  of 
the  cortex  is  complete,  and  nothing  remains  to  hold 
the  hair  together.  There  is  no  fatty  degeneration 
present." 

S.  KoHN  (286),  in  1881,  writes:  ''The  httle  clear 
bodies  on  the  outer  filaments  of  the  split  nodes,  which 
are  not  altered  by  different  methods  of  handling,  shut 
out  the  parasitic  nature  of  the  disease,  because  they 
are  only  occasionally  met  with,  never  in  the  nodes  nor 

f 


ATROnilA   PILOKU:SI   PROPRIA.  151 

other  parts  of  the  hair,  and  because  they  are  out  of 
aU  proportion  to  the  disease.  They  are  merely  deposits 
from  the  outer  air.  The  theory  of  atropliy  has  sup- 
port in  the  following  microscopic  appearances:  In 
treating  the  hair- shaft  with  concentrated  caustic  potash 
or  acetic  acid,  a  swelling  of  the  medulla  is  caused.  This 
swelling  we  have  never  found  in  a  node,  but  only  in 
the  beginiiing  stage  of  the  disease  when  no  node  could 
be  seen.  In  those  places  where  there  are  nodes,  there 
is  no  medulla.  The  nodes  under  the  microscope  ap- 
pear as  brush-hke  masses  of  split-up  fibres.  The  fibres 
are  partly  directed  outwards,  and  in  part,  the  opposite 
fibres  are  shoved  into  each  other.  If  the  hair  is  broken 
off,  we  will  find  the  remaining  portion  looking  like  a 
brush  with  its  fibres  spreading  outwards.  Between 
the  stage  of  swelling  of  the  medulla  and  the  stage  in 
which  the  broken  node  is  met  with,  there  is  a  stage  in 
which  holes  are  formed  in  the  cortex.  One  sees  plainly 
that  the  single  cells  of  the  cortex  are  loosened  and  be- 
ginning to  fall  apart.  Transverse  sections  of  the  nodes 
show  a  jmrt  of  the  medulla  replaced  by  air.  ''  Michel- 
son  (40)  says,  in  Ziemssen's  Handbuch,  Vol.  XIV., 
*' In  some  places  on  the  hair  there  is  the  appearance 
as  if  two  brushes  were  pushed  end  to  end;  at  a  little 
distance  from  them  the  shaft  is  split  into  several 
fascicuH,  whose  ends  are  frayed  and  present  a  broom- 
like  appearance.  As  a  rule,  the  partial  longitudinal 
splits  are  very  nearly  in  the  middle  of  the  shaft,  and 
if  any  medulla  is  present,  it  will  be  destroyed.  Some- 
times, however,  the  hair  splits  into  a  larger  fasciculus 
embracing  the  medulla,  and  into  one  or  more  smaller 
fascicuU.  The  affected  part  of  the  hair,  akeady  de- 
prived of  its  cuticle,  bursts,  and  perhaps,  with  its 
fibres  spread  out  in  aU  directions,  forms  an  admirable 
net  to  catch  atmospheric  dust.  All  sorts  of  particles 
are  deposited,   and  sometimes  caught    so    fast    that 


152  DISEASES   OF  THE   HAIR   AND   SCALP. 

they  can  not  be  dislodged  by  any  mode  of  handling. 
Specially  striking  are  the  dark,  sharp-cornered  coal- 
particles,  and  the  blue  ultramarine  gi-ains.  A  good 
deal  of  air  finds  lodgment  also  in  the  sphts  and  holes. 
In  the  microscopical  examination,  this  air  a\411  be  more 
or  less  rapidly  expelled  from  the  hair  by  the  fluid  me- 
dium, and  the  appearance  thus  caused  was  the  founda- 
tion for  Beigel's  theory  of  the  development  of  gas 
within  the  hair,  as  the  cause  of  the  disease.  We  have 
ne^'er  found  any  parasite  present.  Many  hairs  in  the 
neighborhood  of  the  affected  hairs  present  an  atropine 
appearance."  Hans  Hebra  (16)  describes  the  hair 
roots  as  "presenting  a  shrunken  appearance,  and  ap- 
proximating to  the  size  of  the  shaft."  Giovannini 
(237  ap.)  says  that  the  hairs  have  a  triangular  contour. 

From  consideration  of  these  various  microscopical 
appearances,  we  learn  that  there  is  first  a  swelling  of 
the  shaft,  forming  the  node;  then  a  transverse  fracture, 
taking  place  through  the  node,  combined  with  a  spHt- 
ting  up  of  the  hair-fibres;  and  lastly  a  lesion  of  con- 
tuiuity  occurs,  and  a  brush -like  end  is  presented  by 
the  broken  hair.  P'urther,  in  the  node  there  is  no 
medulla  present.  Michelson,  Pye-Smith,  and  Wilson 
seem  to  find  the  beginning  of  the  disease  in  the  cortical 
portion  of  the  hair;  while  Kohn,  and  Eichhorst,  regard 
degeneration  of  the  medulla  as  the  first  step  in  the 
process.  The  hair-roots  are  either  unchanged  or  else 
slightly  atrophied. 

Lesser  (2SS)  has  repoi-ted  a  case  of  "ringed  hair" 
which  presented  the  appearance  of  trichorrhexis  no- 1 
dosa,  excepting  that,  in  his  case,  the  fracture  always  1 
took  place  through  the  constricted  portion,  which  he  i 
believes  to  be  the  diseased  part.     The  beguming  of  the 
fracture  in  Ms  case  was  marked  by  a  transverse  break- 
ing of  the  cuticle,  which  often  ran  in  a  circular  manner 
quite  around  the  hair,  and  the  raised  epidermis  formed 


ATROPHIA   PILORUM   PROPRIA.  153 

a  sort  of  collar.  In  a  case  of  W.  G.  Smith  (303),  the 
fracture  likewise  occurred  in  the  internodular  por- 
tions. These  last  two  cases  were  doubtless  instances 
of  aplasia  pilorum  propria.  In  parasitic  diseases  of  the 
scalp,  the  appearances  of  trichorrhexis  nodosa  are  not 
infrequently  observed. 

Treatment.  — Thus  far  all  modes  of  treatment  have 
proved  very  unsatisfactory.  All  sorts  of  applications 
have  been  made  to  the  affected  parts,  generally  of  a 
stimulating  character,  and  particularly  the  various 
forms  of  mercurials,  but  without  curative  effect.  Gam- 
BERixi  (59)  recommends  either  bathing  the  part  with 
a  lotion,  composed  of  15  grammes  of  subcarbonate  of 
potassium  to  150  grammes  of  dilute  alcohol  (say  3 
drachms  to  4  ounces);  or  using  inunctions  of  tannic 
acid  or  oil  of  cade.  Schwimmer  (301)  advises  that 
an  ointment  composed  of  a  half  gramme  (gr.  vii)  of 
oxide  of  zinc,  1  gramme  (gr.  xv)  of  washed  sulphur, 
and  10  grammes  (  3  ijss)  of  simple  ointment,  be  rubbed 
in  morning  and  evening. 

But  the  chief  reliance  is  placed  upon  shaving,  with 
the  hope  that  it  will  stimulate  the  nutrition  of  the  hair, 
and  that  after  a  time  the  hair  will  grow  in  a  proper 
manner.  Wolfberg  (312)  founds  his  treatment  upon 
his  theory,  and  advises  that  the  hair  be  left  entirely 
alone.  As  other  treatments  have  failed  of  doing  any 
good,  it  would  seem  worth  while  trying  this  expectant 
plan  in  cases  in  which  handling  the  beard  is  a  possible 
etiological  factor. 

Aplasia  Pilorum  Propria. 

Synonyms: — Aplasia  pilorum  intermittens;  Monile- 
thrix; Moniliform  hairs;  Cheveux  moniliformes. 

This  is  the  third  variety  of  atrophy  of  the  hair,  that 
has  often  been  mistaken  for  trichorrhexis  nodosa,  as 
it  too  presents  nodes  along  the  hair-shaft.  It  differs, 
however,  from  that  condition  principally  in  two  par- 


154:  DISEASES   OF   THE   HAIR  AND   SCALP. 

ticulars,  viz. :  the  nodes  are  here  the  normal  parts  of 
the  hair,  while  the  internodular  portions  are  the  abnor- 
mal parts;  and  the  fracture  takes  place  through  the 
internodular  parts. 

Symptoms. — The  disease  is  congenital  in  nearly  all 
cases,  and  appears  in  infancy.  A  few  cases  have 
come  on  later  in  life.  Usually  the  child  is  born  with 
apparently  normal  hair,  but  in  the  course  of  a  few 
weeks  the  hair  breaks  off  either  over  the  whole  head 
or  in  patches,  and  the  scalp  assumes  the  appearances 
of  keratosis  pilaris  or  of  trichophytosis  capitis,  being 
covered  by  small,  scaly,  elevated  cones,  and  it  is  some- 
what reddened.  Pustules  may  form  on  it.  Sometimes 
complete  baldness  results,  and  many  cases  of  congeni- 
tal alopecia  are  doubtless  due  to  this  disease,  the  scalp 
having  been  destroyed,  as  evidenced  by  the  presence 
of  many  small  cicatricial  points  scattered  over  it. 
From  the  little  scaly  hair-cones  the  short,  stubby  hairs 
protrude.  They  look  as  if  scorched,  and  some  are 
bent.  They  are  very  brittle,  and  easily  break  on  slight 
traction.  They  are  seldom  longer  than  a  quarter  of 
an  inch;  they  may  present  simply  as  black  points. 
If  examined  with  care  many  of  the  hairs  will  show 
fusiform  swellings  with  contractures  between,  through 
which  fracture  has  taken  place.  After  a  time  partial 
recovery  may  take  place,  but  it  is  never  complete. 
All  the  hairy  regions  of  the  body  may  be  affected,  and 
there  may  be  a  general  keratosis  pilaris. 

Apart  from  the  loss  of  hair,  the  subjects  of  the  dis- 
ease may  be  in  good  health;  sometimes  they  may  be 
in  poor  physical  condition. 

Etiology. — In  many  cases  the  disease  is  inherited, 
and  seems  to  be  a  deformity  of  the  skin  rather  than  a 
disease,  just  as  is  icthyosis.    It  is  also  prone  to  descend  ' 
in  the  same  sex,  and  to  affect  more  than  one  member 
of  a  family,  a  pecuharity  shared  by  several  other  der-  J 


ATROPHIA  PILORUM  PR0PRL4.  155 

matoses.  Thus  Sabouraud  (2tL3  ap.)  traced  the  disease 
back  to  a  great-grandfather  and  found  evidence  of 
seventeen  cases  in  the  family.  Lesser  (241  ap.)  re- 
ports a  case  of  a  man  and  two  sons,  and  a  history  of 
eight  cases  in  the  same  family  in  two  generations,  the 
descent  being  direct  and  through  the  males.  Hudelo 
(239  ap.)  reports  the  case  of  a  girl  whose  mother  had 
the  disease,  that  was  hereditary  on  the  mother's  side 
back  to  her  great-grandfather.  A  sister  of  the  patient 
had  weak  hair.  Tennesox  (251  ap.)  met  with  three 
cases,  all  girls,  in  a  family  of  five,  the  father  of  whom 
had  the  disease,  as  w^ell  as  his  brother  and  sister;  and 
Payne  (216  ap.)  reports  two  brothers  with  the  dis- 
ease. Isolated  cases  do  arise,  as  well  as  those  in  which 
there  is  no  history  of  inheritance.  We  do  not  know 
the  cause  of  the  disease. 

Pathology. — Under  the  microscope  the  nodes  on 
the  hair  show  better  than  when  viewed  by  the  naked 
eye.  Indeed,  in  some  fine  hairs  the  nodes  are  only 
seen  by  the  microscope.  The  hairs  will  be  found  to 
have  on  them  at  regular  intervals  alternate  strictures, 
or  narrow  places,  and  swellings.  The  latter  are  about 
1  mm.  long,  fusiform  in  shape,  of  darker  color  than 
the  narrow  portions,  and  about  three  times  longer  and 
three  times  wider  than  they  are.  The  difference 
in  color  is  due  to  the  fact  that  the  constricted  parts 
contain  neither  medulla  nor  pigment,  and  may  consist 
of  the  cuticle  layer  of  the  hair  alone.  The  hair-bulbs 
are  atrophied.  It  has  been  noted  by  Beatty  and 
Scott  (231:  ap.)  and  by  Sabouraud  (219  ap.)  that  the 
hair  examined  in  sections  of  the  skin  shows  a  deformity 
of  the  Huxley's  layer  of  the  root- sheath  at  the  part 
corresponding  to  a  node.  The  nodes  are  all  along  the 
hair  from  root  to  point.  Fracture  takes  place  through 
the  internodes,  and  frayed-out  or  brush-like  ends  may 
or  may  not  be  found.    Sabouraud  found  that  the 


156  DISEASES   OF  THE   HAIR  AND   SCALP. 

constrictions  formed  at  two  days'  intervals^  and  Ja- 
mieson's  (240  ap.)  experiments  led  to  the  same  result. 

Treatment  thus  far  has  been  of  none  effect.  Stim- 
ulation might  be  tried,  but  the  prognosis  is  bad. 

Under  the  name  of  end  atrophy  Crocker  describes 
a  case,  reported  by  McMurray  (242  ap.),  in  which  the 
distal  ends  of  the  hairs  were  bulbous  and  of  lighter 
shade  than  the  rest  of  the  hair. 

Besides  the  foregoing  atrophic  conditions,  there  are 
certain  other  somewhat  allied  deformities  that  are 
here  noted. 

There  is  also  a  condition  of  the  hair  called  ^'P7mg- 
mesis,^^  in  which  feathers  adorn  the  body  instead  of 
hair.  T.  Robinson  (299)  cites  a  case  of  this  natm^e, 
which  occurred  in  a  boy  who  was  exhibited  in  Bremen, 
and  was  reported  upon  in  Bauerle^s  Magazine  for 
1831.  The  boy's  head  is  said  to  have  been  covered 
with  feathers  in  place  of  hair. 

Ferber  (282)  reports  two  pecuHar  cases  of  change  in 
the  texture  of  the  hair.  Both  patients  were  nervous 
individuals,  and  their  hair  in  a  few  hours  would  change 
from  being  soft  and  curly,  to  become  straight  and 
bristly.  The  change  followed,  m  one  case,  nightly  pol- 
lutions, and  in  the  other  any  special  deterioration  of 
the  always  feeble  health.  After  a  time  the  hair  would 
return  to  its  usual  condition. 

NoDULi  Laqueati  is  that  condition  of  the  hair 
in  which  it  seems  to  tie  itself  into  knots.  The  hair 
is  usually  dry  and  curly.  According  to  Michelson 
(40),  the  condition  is  common  in  trichorrhexis  nodosa. 
The  loop  of  the  knot  forms  an  excellent  net  to 
catch  dust  and  fl}ing  particles,  and  hence  under 
the  microscope,  all  sorts  of  dust  elements  are  found 
with  the  hair.  A  case  of  this  sort  is  repoii^ed  by 
L.    D.   Bulkley  (277),  which  oiJcmTcd  in  the  pubic 


ATROPHIA   P:L0RUM   PROPRIA.  157 

liair  of  a  man  who  was  troubled  with  itching  and 
sweating  of  the  genitals.  The  hair  looked  as  if  in- 
vested with  the  nits  of  pediculi,  but  the  microscope 
showed  that  the  appearance  was  due  to  the  presence 
of  a  double  knot  on  each  hair,  composed  of  several 
turns. 

I  have  recently  met  with  a  case  of  undoubted  in- 
chorrhexis  nodosa  of  the  beard,  in  which  this  knotting 
of  the  hair  occurred.  The  patient  was  of  unsound 
mind,  and  kept  constantly  pulhng  at  his  beard,  and  to 
this  habit  was  ascribed  the  knotting.  Michelson  as- 
cribes the  disease  to  improper  combing,  and  pulling  of 
the  beard  through  the  fingers. 


CHAPTEE    IX. 

HYPERTROPHIA  PILORUM. 

Synonyms:— Hypertrichosis;  Hirsuties;  Trichauxis; 
Pohi;richia;  Dasyma;  Dasytes;  Trichosis  hirsuties; 
Foils  accidentels  (Fr.);  Superfluous  hair;  Hairiness. 
(Eng). 

Defixitiox: — A  growth  of  hair  which  is  either  ab- 
normal in  amount  or  occurs  in  places  where,  normally, 
only  lanugo  hairs  are  present.  While  it  is  normal  for 
a  man  to  have  a  beard  from  four  to  six  inches  in  length, 
it  would  be  abnormal  for  him  to  have  one  reaching  to 
his  feet.  Again,  while  normally  the  hair  grows  thick 
and  strong  upon  the  cheeks,  chin,  and  upper  Hp  of  a 
man  after  puberty,  should  such  a  growth  occur  upon 
the  face  of  a  woman  it  would  be  abnormal. 

Symptoms. — Hypertrichosis  may  be  general  or  par- 
tial, congenital  or  acquired.  Of  these  the  general  form, 
liyperfricliosis  nniversah's,  is  very  rare,  w^hile  the  ac- 
quired form,  or  hypertrichosis  partialis,  is  the  most 
frequent,  and  is  f amihar  to  every  one  in  the  cases  of  the 
unfortmiate  bearded  women. 

Hypertrichosis  universalis  is  generally  congenital, 
and,  in  spite  of  its  name,  does  not  affect  the 
whole  body.  Hair  never  develops,  even  in  tins  dis- 
ease, in  places  in  which  normally  no  hair  is  found.  It 
is  not  met  with,  therefore,  upon  the  palms  of  the 
hands,  the  soles  of  the  feet,  the  backs  of  the  last  pha- 
langes of  the  fingers  and  toes,  the  inside  of  the  labia 
majora,  the  prepuce,  ot  on  the  glans  penis.  Subjects 
of  this  malady  are  usually  born  covered  more  or  less 


HYPERTROPHIA   PILORUM.  150 

thickly  with  hair,  which  may  be  Hght  or  dark  in  color. 
This  continues  growing  longer,  coarser,  and  darker  till 
it  reaches  its  full  development.  As  a  rule  the  long 
hair  covering  the  body  is  fine,  resembhng  more  the 
hair  of  the  head  than  of  the  beard,  as  is  also  the  case 
with  the  hair  on  the  face  of  these  persons.  It  follows 
a  definite  direction  in  growing,  and  this  is  away  from 
certain  well-defined  centres.  Thus  on  the  back  it 
grows  on  each  side  downward  and  outward  from  the 
spinal  column;  on  the  forehead  away  from  the  middle 
line,  following  the  lines  of  the  eyebrows;  on  the  face, 
also,  from  a  line  running  down  the  middle.  With  this 
excessive  growth  of  hair  there  is  usually  combined  a 
deficiency  of  teeth,  specially  marked  in  the  upper  jaw. 
MiCHELSON  (353)  has  seen  a  family  which  was  very 
hairy,  in  many  members  of  which  there  was  a  defect 
of  all  five  back  teeth,  the  alveolar  processes  for  the 
same  being  wanting. 

These  homines  pilosi  are  met  with  in  all  pai^s  of  the 
world.  Thus  we  have  records  of  the  Kostroma  family 
from  Eussia,  a  father  and  son.  They  first  attracted 
notice  some  twelve  years  ago,  and  were  described  in  a 
number  of  European  medical  journals.  The  father 
died  about  four  years  ago  in  Paris.  The  son  was  on 
exhibition  in  this  country  in  1886.  Nothing  is  known 
of  the  parentage  of  the  father,  nor  have  I  found  any 
record  of  the  boy's  mother.  An  excellent  likeness  and 
description  of  the  father  is  given  in  the  last  volume  of 
Ziemssen's  Hanclhuch  der  speciellen  Fathologie  unci 
TJierapie.  The  son  was  in  188G  sixteen  years  of  age, 
and  looked  like  a  well-developed  boy,  though  some- 
what under  the  average  height.  He  appeared  to  be 
muscular,  and  was  active  and  energetic  in  his  actions. 
He  seemed  intelligent,  and  certainly  showed  acuteness 
in  the  rapidity  and  correctness  with  which  he  gave  me 
change  for  a  dollar  bill  when  I  bought  his  photograph. 


160 


DISEASES   OF   THE   HAIR  AXD   SCALP. 


He  spoke  his  native  language  with  great  rapidity,  and 
has  picked  up  some  German  and  Enghsh  words.  His 
agent  said  that  he  was  docile,  and  his  health  was  good. 
His  head  was  covered  with  a  luxuriant  growth  of  fine, 
glossy  hair  of  blonde  color,  some  six  inches  long.  This 
extended  further  down  on  the  neck  than  is  usual.  The 
scalp  was  normal,  white  and  soft.     Coming  forward, 


The  Dog-faced  Boy. 

the  hair  grew  well  down  on  the  forehead,  and  then 
continued  over  the  whole  face,  though  on  the  face  it 
was  finer  and  lighter  in  color  than  on  the  head.  The 
facial  hair  did  not  resemble  in  texture  the  usual  hair 
of  the  beard,  even  where  it  grew  in  the  places  ordina- 
rily occupied  by  that  growth  in  men,  but  was  much 
softer.     Upon  the  upper  lip  there  was  a  space,  occupy- 


HYPERTROPHIA    PILORUM.  161 

ing  about  the  middle  third,  where  the  growth  was  very 
scanty.  Under  the  eyes  the  hair  also  was  absent  for  a 
space  of  about  half  an  inch.  Otherwise  the  whole  face 
was  covered  with  long  hair,  growing  from  the  inside 
and  outside  of  the  nose,  and  continuing  all  down  the 
neck.  There  was  also  a  luxuriant  growth  of  hair  from 
the  inside  and  outside  of  the  ears.  Under  each  eye 
there  was  a  group  of  three  or  four  black  hairs.  The 
hair  of  the  face  was  some  four  inches  long.  Upon  the 
body  the  most  remarkable  growth  was  down  the  spinal 
column,  where  the  hair  stood  out  not  unlike  a  horse's 
mane.  The  rest  of  the  trunk  and  the  extremities 
were  completely  covered  with  hair,  but  not  veiy  much 
more  so  than  in  not  a  few  other  hairy  people.  The 
backs  of  the  hands  presented  nothing  remarkable.  On 
the  body  the  hair  was  exceedingly  fine  and  delicate, 
and  more  fluffy  than  that  on  the  head  and  face. 
There  was  a  cast  in  his  left  eye,  and  he  was  near- 
sighted. He  had  only  five  teeth,  two  uiiper  canine, 
and  two  lateral,  and  one  middle  lower  incisor.  The 
alveolar  ridges  show  no  sign  of  there  ever  having 
been  any  more  teeth.  The  teeth  he  has  are  badly 
shaped  and  discolored.  His  father  is  said  to  have  had 
no  teeth  till  he  w^as  seventeen  years  old,  and  then  only 
four  in  the  lower  and  one  in  the  upper  jaw.  The  Lon- 
don Lancet  in  IS 73,  reported  the  boy  as  having  fom- 
incisor  teeth  in  the  lower  jaw,  so  he  must  have  lost 
one. 

Other  instances  of  universal  hypertrichosis  have 
been  reported.  Thus  the  case  of  Barbara  Ursler  is 
cited  by  Stricker  (370)  as  occurring  in  the  seventeenth 
century.  This  woman's  whole  body  was  covered  with 
blonde,  soft,  curly  hair,  and  she  had  a  thick  beard  reach- 
ing to  her  girdle.  In  a  book  pubhshed  in  1642  and  en- 
titled Aldrovandi  Monstrornm  Historia  there  is  an 
account  of  a  hairy  family  consisting  of  the  father  aged 


162  DISEASES  OF  THE  HAIR  AND  SCALP. 

forty,  a  son  aged  twenty,  and  two  daughters  aged 
eight  and  twelve.  They  came  from  the  Canary 
Islands,  and  were  covered  with  hair,  excepting  that 
the  daughter's  lips,  nose,  neck,  breast,  and  hands  were 
smooth.  In  1851,  Chowne  (32 S)  reported  a  case  of 
iniiversal  hirsuties  occurring  in  a  Swiss  woman  twenty 
years  of  age.  Her  body  was  covered  with  hair  except- 
ing on  the  breasts  and  chest,  which  were  free  of  the 
growth.  In  Beigel's  (41:)  book  on  The  Human  Hair, 
accounts  of  several  cases  of  this  deformity  are  given, 
viz.:  that  of  Julia  Pastrana,  a  Spanish  dancer;  and  of 
Shewe  Maon  and  his  daughter  Maphoon,  in  India. 
The  latter 's  second  child  was  hairy  hke  its  mother.  In 
the  father  and  daughter  there  was  an  absence  of  the 
canine  and  molar  teeth.  But  it  is  useless  to  multiply 
examples,  as  the  foregoing  cases  are  sufficient. 

Oi  partial  congenital  hypertrichosis  we  have  an  im- 
mense number  of  examples.  This  condition  is  apt  to 
be  of  the  nature  of  na?vus.  It  must  be  held  in 
mind  that  the  distinction  between  a  locahzed  hy- 
pertrichosis and  a  naevus  is  made  mostly  upon  the 
color  of  the  underlying  skin.  In  the  former  case 
the  skin  is  perfectly  normal,  while  in  the  latter  it 
is  pigmented  and  may  be  otherwise  altered.  Thus 
we  have,  in  the  Lancet  of  1869,  an  account  of  a 
Mexican  woman  who  had  a  nsevus  pilosus  extending, 
like  a  pair  of  bathing  trowsers,  from  the  umbihcus  an- 
teriorly and  the  sixth  dorsal  vertebra  posteriorly,  to 
about  half-way  down  the  thighs,  covering  the  but- 
tocks. Cummin  (329)  mentions  the  case  of  a  lady  who 
was  noted  for  the  beauty  of  her  face,  whose  body  from 
breast  to  knee  was  covered  with  a  profusion  of  black, 
thick,  bristly  hair.  Waldeyer  (83)  reports  the  case  of  a 
girl  nine  years  of  age,  who  had  a  lock  of  hair  running 
from  the  first  to  the  fourth  lumbar  vertebra,  and  a 
emaUer  one  from  the  third  to  the  fourth  cervical  verte- 


HYPERTUOPHIA    PILORUM.  163 

bra.  These  localized  and  partial  cases  of  hypertri- 
chosis are  most  frequently  met  with  in  the  sacral  or 
lumbar  region,  and  not  infrequently  are  associated 
with  spina  bifida.  Ornsteix  (2S1  and  282  ap.)  says 
that  sacral  hypertrichosis  is  common  in  Greeks,  and 
reports  two  cases  of  tails  in  Greek  soldiers,  one  a 
quarter  of  an  inch  long  and  cone  shaped,  the  other  not 
quite  so  long  and  stumpy. 

Partial  acquired  hypertrichosis  is  more  common 
than  the  congenital  variety,  and  takes  the  form  either 
of  an  excessive  growth  of  hair  in  regions  wliere  it  is 
usually  found,  or  of  the  development  of  hair  in  regions 
usually  hairless  or  only  provided  with  downy  or  lanugo 
hairs. 

The  following  cases  are  instances  of  excessive  growth 
and  precocious  development.  Chow^ne  (3JS)  speaks  of 
a  boy,  eight  years  of  age,  who  had  the  whiskers  of  a 
man.  Beigel  (321)  has  seen  a  six-year-old  girl  with 
pudenda  hke  a  twenty-year-old  woman,  both  in  shape 
and  hair.  This  form  is  called  '^  Hetero -chronic  of 
Hair"  by  Bartels  (318).  As  cases  of  excessive 
growth  may  be  cited  the  following:  Leonard  (04) 
mentions  the  case  of  a  man  in  his  neighborhood  whose 
beard  measured  seven  feet  six  and  a  half  inches  in 
length.  Other  instances  of  excessive  length  of  beard 
are  met  with  in  medical  literature,  such  as  that  of  the 
carpenter  at  Eidam,  whose  beard  was  nine  feet  long, 
and  who  was  accustomed  to  carry  it  in  a  pocket  de- 
voted to  the  purpose;  and  that  of  the  Biirgermeister 
of  Braunau  whose  beard  reached  to  the  ground.  Wil- 
son (378)  met  with  a  lady  who  was  five  feet  five  in- 
ches in  height,  whose  hair,  when  she  walked,  trailed 
three  or  four  inches  on  the  floor.  Many  men  have  an 
excess  of  hair  upon  the  chest  and  shoulders.  Hair  is 
generally  more  developed  upon  the  forearm  than  upon 
the  upper  arm,  and  upon  the  leg  than  upon  the  thigh. 


164  DISEASES   OF  THE   HAIR  AND   SCALP. 

As  men  grow  old  they  are  apt  to  have  long  hair  grow 
from  the  nostrils  and  the  ears.  These  are  instances  of 
the  growth  of  strong  hair  where  normahy  lanngo  hairs 
alone  are  present.  But  these  cases  are  interesting  only 
as  curiosities  and  as  subjects  of  study. 

Bearded  Women. — The  growth   of    the  beard  in 
women  is  the  form  of  hypertrichosis  which  concerns 


Bearded  Woman. 

US  most,  as  it  is  the  deformity  which  w^e  will  be  called 
upon  to  cure.  It  has  been  called  heterogenic.  As  women 
grow  old,  especially  after  they  have  passed  through  the 
climacteric  period  of  middle  life,  a  slight  mustaclie  or 
a  few  straggling  dark  hairs  on  other  parts  of  the  face 
often  appear.  These  will  seldom  annoy  them  much, 
as  they  are  accepted  as  evidences  of  advancing  years. 
The  case  is  very  different  when  a  young  woman  is 


I 


HYPERTKOPHIA   PILORUM.  165 

afflicted  with  a  beard,  and  many  of  the  patients  who 
apply  for  relief  froni  their  facial  hair  are  between 
twenty  and  thirty-live  years  old.  The  hair  generally 
begins  to  grow  so  as  to  be  noticeable  at  about  the 
eighteenth  year  of  age.  To  get  rid  of  the  trouble  the 
tweezers  are  first  resorted  to,  and  this  only  makes 
matters  worse.  Then  depilatories  are  tried  whicli 
have  but  a  passing  effect,  and  some  of  them  leave  bad 
scars.  Sometimes  burning  is  attempted,  and  as  a  final 
refuge  the  razor  is  used.  All  the  time  the  hair  grows 
coarser  and  more  abundant.  Were  this  all,  though  it 
would  be  bad  enough,  these  cases  would  not  so  greatly 
need  our  aid.  The  deformity  is  only  the  beginning  of 
evils.  These  women  shun  company,  keep  themselves 
shut  up  all  day,  their  health  deteriorates,  and,  con- 
stantly brooding  over  their  misfortune,  they  are  prone 
to  become  hypochondriacal  and  melancholic.  Anyone 
devoted  to  dermatological  practice  must  have  seen 
these  nervous,  sensitive  women,  whose  health  is 
broken  and  spirits  depressed  on  account  of,  it  may  be, 
no  very  formidable  facial  hirsuties.  The  amount  of 
hair  presented  by  these  cases  varies.  Perhaps  the 
commonest  growth  is  a  mustache  alone.  In  most  of 
my  cases  the  hair  has  grown  thickest  and  coarsest 
under  the  chin  and  upon  the  front  of  the  throat. 
It  is  rare,  even  in  the  best  developed  cases,  to  have 
much  hair  under  the  lower  lip.  Sometimes  the  growth 
is  as  complete,  as  heavy,  and  as  coarse  as  is  met  with 
in  men.  An  excellent  account  of  such  a  case  is  de- 
scribed by  DuHRiNG  (330).  The  skin  of  many  of  my 
cases  has  been  coarse,  muddy,  greasy,  and  studded 
with  acne. 

From  time  to  time  cases  of  transitoru  hj/jiertrichosis 
have  been  reported.  This  has  been  noticed  during  the 
treatment  of  a  fractured  limb,  the  hair  being  much 
more  prominent  upon  the  part  that  has  been  kept  quiet 


166  DISEASES   OF   THE   HAIR  AND   SCALP. 

and  warm.  In  some  of  these  cases  the  increase  is  pro- 
bably more  apparent  than  real,  the  hair  not  having 
been  rubbed  off  by  friction.  Likewise,  after  injury 
to  nerves  the  hair  sometimes  becomes  hypertrophied, 
only  to  fall  off  after  recovery.  Continued  irritation 
of  a  part,  as  by  blisters,  may  stinmlate  hair-growth 
which  may  or  may  not  be  transitory.  The  most  in- 
teresting of  this  group  of  cases  are  those  instances 
of  hirsuties  occurring  during  pregnancy  or  amenor- 
rhoea,  and  disappearing  again  some  months  after  par- 
turition. Wilson  reported  a  case  of  delayed  appear- 
ance of  menstruation  in  which  hair  grew  upon  the 
face.  After  the  menstrual  function  was  established, 
the  hair  ceased  to  grow  and  gradually  fell  off.  Thin 
(291  ap.)  and  Gottheil  (263  ap.)  have  reported  cases 
of  hirsuties  that  disappeared  after  conception. 

Etiology. ^ — The  cause  of  hypertrichosis  is  very  ob- 
scure in  some  of  its  forms,  while  in  other  varieties 
we  can  more  readil}"  discover  it.  In  universal  hirsuties 
heredity  plays  an  important  part.  Such  instances  as 
those  of  tlie  Kostroma  father  and  son  ;  of  Shewe 
Maon,  and  his  daughter  and  grandchild,  and  others 
like  them,  attest  this  fact.  But  hereditary  tendencies 
will  not  explain  the  first  appearance  of  these  congenital 
cases.  YiRCHOw  (375)  endeavored  to  account  for  them 
upon  the  theory  of  nervous  influence,  founded  upon 
the  fact  that  in  the  Kostroma  people  the  lack  of  devel- 
opment of  the  teeth  and  jaws  was  in  the  same  zone 
of  nervous  influence  as  was  the  over-development  of 
the  hair  on  the  forehead,  nose,  cheeks,  and  ears;  these 
regions  all  being  supplied  by  branches  of  the  trigem- 
inus or  fifth  cranial  nerve.  Parreydt,  quoted  by 
Geyl  (5C)  ap.),  thought  that  those  who  had  large  teeth 
were  apt  to  have  a  profuse  growth.  This  theory  is 
not  borne  out  by  facts.     Atavism  is  another  theory 


HYPERTROPHIA   PILORUM.  1G7 

to  account  for  these  cases.  When  we  remember  that 
the  foetus  is  completely  covered  with  hair  of  some 
length  and  coarseness,  though  not  coarse,  there  is  good 
ground  for  believing  that  Unxa's*  theory  of  congenital 
hypertrichosis  is  right,  namely  :  '^That  it  is  due  to  a 
persistence  of  the  foetal  or  primitive  hair  ;  the  change 
of  type  between  the  primitive  and  permanent  hair  not 
taking  place."  While  normally  tlie  change  in  type 
does  take  place  and  the  primitive  hair  of  most  of  the 
body  is  replaced  with  lanugo  hair,  in  some  individuals 
for  some  unknown  cause  the  primitive  hair  remains, 
grows  stronger,  and  we  have  the  homines  pilosi. 

At  the  present  time  it  is  hardly  necessary  for  us  too 
gravely  to  discuss  the  theories  of  maternal  impressions, 
fecundation  of  the  human  female  by  a  hairy  animal, 
and  the  like. 

The  cause  of  acquired  hirsuties  is,  in  some  cases,  not 
far  to  seek.  Heat  and  moisture  will  apparently  in- 
crease the  growth  of  hair,  just  as  they  favor  the 
growth  of  vegetable  life.  Thus  the  hair  has  grown 
luxuriantly  under  the  stimulation  of  poultices,  and  on 
the  limbs  when  confined  in  a  fracture  box.  To  these 
factors  must  be  added  an  increase  of  the  flow  of  blood 
to  the  part,  which  will  stimulate  hair-growth  indepen- 
dently of  heat  and  moisture.  At  least  Prentiss'  (134) 
case  of  hair  growing  more  luxuriantly  and  coarser  under 
the  use  of  pilocarpin,  which  causes  hyperaemia  of  the 
skin,  would  seem  to  indicate  this.  Hypertrichosis  fol- 
lowing injury  to  nerves  is  probably  dependent  upon 
vaso-motor  disturbances.  The  growth  of  hair  upon 
exposed  parts,  as  upon  the  arms  and  chests  of  laboring 
men,  sailors,  and  the  hke,  is  due  to  the  local  irritation 
of  the  sun  and  wind. 

Now  we  come  to  the  more  obscure  cause  of  facial 

*  Ziemssen's  Handbiich,  Vol.  XIV.,  p  50. 


lOS  DISEASES   OF   THE   HAIR   AND   SCALP. 

hirsuties  in  women.  In  the  majority  of  cases  it  will 
be  found  that  the  deformity  is  hereditary  on  the  fe- 
male side,  the  mother,  maternal  aunt,  or  maternal 
grandmother  having  hirsuties.  To  account  for  this, 
numerous  hypotheses  have  been  formed.  Probably 
the  one  most  generally  accepted  is  that  it  is  in  some 
way  connected  with  derangement  of  the  uterus  and 
appendages.  Because  in  some  bearded  women  there 
has  been  some  evident  derangement  of  the  sexual  or- 
gans, it  has  been  affirmed  that  some  similar  derange- 
ment is  present  in  all,  just  as  many  of  the  laity  believe 
that  the  too  free  use  of  alcohol  is  the  cause  of  rosacea. 
In  the  cases  I  have  met  with,  the  majority  were  as  free 
from  uterine  trouble  as  the  rest  of  their  sex.  While 
it  is  true  that  some  of  these  women  are  of  masculine 
build,  and  have  a  mascuhne  voice,  most  of  them  do 
not  exliibit  these  characteristics.  The  heaviest  bearded 
of  ni}'  female  patients  was  the  mother  of  three  children, 
and  this  experience  is  not  unique.  In  some  cases,  how- 
ever, there  does  seem  to  be  some  relation  between  the  re- 
productive organs  and  the  growth  of  the  beard.  Seve- 
ral instances  illustrative  of  this  have  been  given  above. 
Eecently,  I  have  met  T\4th  a  case  of  a  woman  with  a 
dark  but  not  very  heavy  beard,  which  began  to  grow 
about  one  month  before  the  birth  of  her  fourth  child. 
The  appearance  of  hair  on  the  face  of  women  who 
have  ceased  to  menstruate  would  suggest  such  re- 
lationship. It  is  a  common  idea  with  women  who 
have  a  good  deal  of  hair  on  the  face,  that  they  have 
brought  it  on  themselves  by  their  endeavors  at  remov-  i 
ing  a  very  sHght,  hardly  perceptible  growth.  This  is  ' 
an  error.  Though  undoubtedly  sha\ing  or  cutting  the 
beard  may  somewhat  increase  its  coarseness,  and  to  a  j 
certain  extent  stimulate  its  growth,  still  it  camiot  make^ 
new  hairs  grow.  It  is  exceedingly  hkely  that  even  if 
these  women  left  the  hair  entirely  alone  it  would  in 


HYPERTROPHIA   PILORUM.  160 

time  become  of  itself  coarse  and  dark,  though  it  would 
be  more  silky. 

The  question  of  the  inheritance  by  the  daughter  of 
the  physical  character  of  the  father  or  male  ancestors 
is  worth  investigating.  By  this  I  mean,  whether  she 
resembles  the  father  in  her  general  build  more  than 
the  mother. 

We  may  sum  up  the  evidence  on  the  etiology  of  fa- 
cial hirsuties  in  this  way :  While  at  times  there  ap- 
pears to  be  a  relation  between  the  uterine,  or,  more 
properly,  the  menstrual  function,  and  the  growth  of 
hair  on  the  face,  shown  by  a  decrease  or  deficiency  of 
the  first,  and  an  increase  of  the  second,  still  in  the  ma- 
jority of  cases  no  such  relation  is  discoverable,  and  it 
must  be  viewed  as  a  defoi-mity  or  freak  of  nature. 

An  interesting  study  of  the  relation  between  hirsuties 
in  women  and  insanity  was  made  by  Hamilton  (339). 
He  regards  hair  growth  on  the  face  in  women  as  the 
inevitable  result  of  the  overactive  and  continuous  ex- 
ercise of  the  uterine  and  ovarian  functions.  He  l)e- 
lieves  it  to  be  of  neuropathic  origin,  connected  with 
disorders  of  the  fifth  cranial  nerve;  and  when  it  occurs 
upon  the  face  of  an  insane  person  it  is  indicative  of  an 
unfavorable  form  of  insanity,  especially  if  the  subject 
has  not  reached  middle  life.  Shaw  (364)  speaks  of  the 
hair  of  chronic  lunatics  changing  from  fine  to  coarse 
and  increasing  in  quantity,  specially  during  or  after  vio- 
lent outbreaks  of  insanity,  and  ascribes  it  to  the  effect 
of  long-continued  increase  of  temperature  of  the  scalp, 
leading  to  a  greater  activity  of  the  hair-bulbs. 

Treatment. — The  treatment  of  hypertrichosis  is  sim- 
ple and  efficacious,  though  laborious  and  tedious.  For 
general  hypertrichosis  we  can  practically  do  nothing. 
This,  not  because  we  cannot  destroy  the  hair  so  that  it 
will  not  grow  again,  but  because  of  the  great  amount 
of  time  it  would  take  to  destroy  it.     Happily,  a  super- 


170  DISEASES  OF   THE   HAIR  AND   SCALP. 

fiuity  of  hair  on  the  body  does  not  incommode  the 
bearer  of  it,  nor,  in  most  cases,  do  him  any  damage. 
One  case,  however,  is  upon  record  where  the  conse- 
quences of  too  much  hair  resulted  in  serious  damage. 
It  is  that  of  a  woman  in  old  times  whose  face  was  very 
beautiful,  and  who  made  an  advantageous  marriage. 
But  the  husband  was  disgusted  to  find  her  body  cov- 
ered from  breast  to  tliighs  T\ith  a  profuse  gi'owth  of 
stiff  coarse  hair,  and  upon  the  strength  of  tliis  he  was 
divorced  from  her  on  the  next  day. 

The  only  form  of  hirsuties  which  urgently  calls  for 
rehef  is  that  occurring  upon  the  face  of  women.  Until 
recently  there  was  no  cure  for  this,  but  in  IS 75  Michel 
(3S0),  of  St.  Louis,  devised  a  method  for  removing  the 
hairs  in  tricliiasis  by  means  of  electrolysis,  which  was 
taken  up  by  Hard  a  way  (34:1),  of  the  same  city,  for 
the  removal  of  superfluous  hair.  Piffard  (29)  in  IS 76 
spoke  of  the  removal  of  superfluous  hair  from  hairy 
naevi  by  this  method  ;  and  Leon  Le  Fort,  in  his  edi- 
tion of  Malgaigne's  ^^  Manuel  de  Medecine  operatoire  " 
in  1877,  pubhshed  his  method  of  destroying  hair  by 
electrolysis,  which  he  had  used  since  IS 75.  As  Mi- 
chel published  his  method  in  IS 75,  to  him  belongs 
the  priority.  The  question  is  often  asked:  *^  Is  the 
removal,  by  this  method,  permanent  ? "  This  question 
may  be  answered,  ^'It  is,  without  a  shadow  of  a 
doubt."  The  object  being  to  destroy  the  papiUa,  and 
that  being  very  small  and  often  placed  at  an  unex- 
pected angle  to  the  surface  of  the  skin,  it  is  not  possi- 
ble always  to  accomplish  this  at  the  first  attempt.  The 
amount  of  success  on  going  over  the  face  the  first  time 
will  vary  with  the  operator,  and,  according  to  his  skill, 
there  will  be  a  return  of  from  twenty  to  fifty  per  cent, 
of  the  hairs  removed.  It  wiU  be  necessary,  therefore, 
to  go  over  the  face  a  second  or  a  third  time,  but  then 
there  will  be  no  return.     At  times,  after  the  dark 


HYPERTROPHIA   PILOKUM.  171 

coarse  hairs  have  been  removed  there  will  be  found  a 
number  of  finer  and  Hghter  hairs.  This  appearance 
is  due  partly  to  the  uncovering  of  these  hairs,  and, 
partly  it  may  be,  to  lanugo  hairs  becoming  stronger 
under  the  stimulation  of  the  operation.  Cases  occur- 
ring in  young  women  are  much  more  tedious  in  their 
treatment  than  those  in  women  past  the  climacte- 
ric, because  while  in  the  latter  the  growth  is  limited  in 
amount,  in  the  former  new  hairs  form  from  new  fol- 
licles, just  as  in  a  young  man's  beard,  and  it  is  impos- 
sible to  tell  when  the  process  will  stop.  It  is  well 
always  to  tell  these  patients  that  they  must  be  pre- 
pared for  a  long  course  of  treatment,  as  only  the  hairs 
that  have  appeared  can  be  destroyed,  and  we  have  no 
means  of  preventing  the  formation  of  new  hairs ; 
that  these  new  hairs  do  not  form  in  the  old  follicles, 
but  are  simjDly  developed  in  time  from  those  already 
in  the  skin.  They  will  have  to  be  treated  from  time 
to  time  during  a  number  of  years  until  all  the  hair 
papillae  have  produced  their  hairs  and  these  have  been 
destroyed.  In  most  cases,  with  proper  care  and  the 
use  of  a  fine  needle,  the  amount  of  scarring  will  be 
very  slight,  amounting  to  nothing  more  than  fine 
punctate  cicatricial  spots.  In  some  peculiarly  irritable 
skins  it  is  very  difficult  to  prevent  the  formation  of 
plainly  visible  scars.  If  the  proper  conditions  are  not 
observed,  the  operator  must  expect  to  produce  a  good 
deal  of  disfigurement. 

The  amount  of  pain  experienced  by  the  patient  will 
vary  greatly.  Some  women  will  complain  bitterly  of 
a  current  of  half  the  strength  that  other  women  will 
bear  with  ease.  Certain  parts  of  the  face  are  far  more 
sensitive  than  others.  The  most  sensitive  points,  ac- 
cording to  my  experience,  are  over  the  ridge  of  the 
lower  jaw  on  each  side  of  the  chin,  and  upon  the 
upper  lip.     On  the  whole,  the  pain  does  not  amount  to 


172 


DISEASES   OF   THE   HAIR  AND  SCALP. 


much.     After  a  time  the  skin  seems  to  become  tolerant 
of  the  action  of  the  current  and  the  patient  no  longer 


complains. 


Twenty  Cell  Galvanic  Battery. 

Hyperpigmentation  may  be  produced  by 
the  operation.  This  is 
a  very  rare  complica- 
tion, and  is  only  men- 
tioned by  way  of  warn- 
ing. I  have  seen  it  in 
two  cases.  Instead  of 
the  redness  which  is 
always  produced  about 
the  point  of  puncture 
fading  away  in  a  few 
days,  it  gives  place  to  a 
dark-1  )rown  stain  which 
may  remain  for  a  num- 
ber of  months. 

The  instruments  nec- 
essary for  the  operation 
are  a  good  twenty  cell  zinc-carbon  (galvanic)  batteiy,  a 


HYPERTROPHIA   PILORUM. 


173 


sponge  electrode,  a  proper  needle-holder,  a  fine  needle, 
a  pair  of  epilating  forceps,  and,  if  the  operator's  eyes 


Leviseur's  Sponge  Electrode. 


are  not  good,  a  lens  of  low  power.     A  galvanometer  is 
not  essential,  but  is  an  aid  to  exactness  in  working. 


WAITE  &  BARTLETT  MF'G.  CD.  NEW  YORK, 


Needle-Holder. 


Any  sponge  electrode  will  answer.     There  are  various 
patterns  of  needle-holders,  any  one  of  which  may  be 


£. EISNER. MX 
Leviseur's  Needle-Holder. 


used.     I  prefer  one  which  is  not  longer  than  three  or 
three  and  a  fourth  inches,  with  a  diameter  of  about 


174:  DISEASES   OF  THE   HAIR  AND   SCALP. 

three-sixteenths  of  an  inch.  It  should  be  long  enough 
to  be  held  with  ease,  and  not  too  long  to  be  readily 
manipulated.  If  the  woman  has  a  large  bust,  a  high 
chest,  and  a  short  neck,  a  short  holder  will  be  found  a 
great  convenience  when  working  under  the  chin. 
Tliere  is  a  form  of  needle-holder  in  the  market  fur- 
nished with  an  attachment  for  cutting  off  the  current 
and  letting  it  flow  again  after  the  needle  is  in  place  in 
the  follicle.  This  I  cannot  recommend,  as  it  causes  a 
very  uncomfortable  shock  to  the  patient,  much  more 
than  that  experienced  in  using  the  method  detailed 
below.  Another  needle-holder,  invented  by  Leviseur 
(272  ap.),  is  ingeniously  arranged  so  that  the  needle  may 
be  placed  at  varying  angles.  The  most  essential  in- 
strument is  the  needle,  and  for  the  best  success  this 
must  be  carefully  chosen.  At  first  the  finest  cambric 
needle  was  used,  and  it  did  fairly  well.  Hardaway 
(342)  recommends  a  needle  made  of  iridium  and  plati- 
mum,  claiming  that  it  will  follow  the  direction  of  the 
hair-follicle  and  hit  the  papilla  more  surely  than  the 
steel  nee.dle  will.  I  have  used  these  needles,  but  have 
not  found  them  so  satisfactory  as  the  steel  ^^  broaches," 
which  are  fine-pointed  steel  needles  used  by  jeweller's 
and  obtained  at  any  jeweller's  supply  store.  They 
come  in  many  grades  of  fineness.  It  is  advisable  to 
have  two  grades,  No.  5  for  the  coarser  hair.  No.  7  for 
the  finer,  and  for  the  lip.  Care  should  be  exercised  in 
selecting  them,  as  they  are  so  fine  that  their  points  are 
sometimes  broken  while  in  the  packages.  A  lens  is  gen  - 
erally  not  needed.  Piffard  (359)  has  inven  ted  a  needle- 
holder  with  a  lens  attachment,  which  he  has  found  use- 
ful. Good  eyesight  and  a  steady  hand  are  the  essentials 
to  be  supplied  by  tlie  operator.  If  he  has  not  these,  he 
had  best  not  attempt  the  operation.  A  good  fight  is  ne- 
cessary for  the  operation,  that  is,  one  that  is  steady  and 
not  glaring.     A  cloudy  day  with  changing  light  is  try- 


HYPERTROPHIA   PILORUM.  175 

'ing  to  the  eyes.  I  have  been  able  to  work  with  much 
comfort  on  dull  days,  even  mider  the  chin,  by  spread- 
ing a  white  napkin  over  the  patient's  throat  and  upper 
chest.  An  operating  or  reclining  chair  is  a  comfoi-t, 
and  the  patient  should  be  so  placed  that  the  part  to  be 
operated  on  is  on  a  level  with  the  operator's  eye. 

The  operation  is  done  in  the  following  manner:  The 
patient,  being  in  position,  is  to  be  given  the  sponge  elec- 
trode attached  to  the  positive  pole  of  the  battery,  and 
told  to  hold  it  in  one  hand.  The  hair  to  be  extract- 
ed is  to  be  seized  with  the  forceps,  and  put  slightly  on 
the  stretch  in  the  direction  in  which  it  naturally  grows. 
The  needle-holder  is  attached  to  the  negative  pole,  and 
held  like  a  pen -holder.  The  needle  is  then  inserted  paral- 
lel with  the  hair  and  into  the  follicle.  One  soon  learns  to 
know  whether  the  follicle  is  entered  or  not  by  the  sense 
of  touch.  When  the  follicle  is  entered  the  needle  glides 
along  smoothly;  when  it  is  not  entered  a  sense  of  re- 
sistance is  communicated  to  the  fingers  as  the  skin  is 
punctured.  The  depth  to  which  the  needle  is  to  be 
thrust  will  vary  with  the  case.  Roughly  speaking,  it 
is  from  one-sixteenth  to  three-sixteenths  of  an  inch. 
The  needle  being  inserted,  the  patient  is  told  to  place 
the  palm  of  the  disengaged  hand  over  the  sponge  elec- 
trode. Watching  the  effect  on  the  skin,  a  slight  hy- 
peraemia  will  be  noticed  about  the  point  of  insertion  of 
tlie  needle,  which  almost  instantly  gives  place  to  a 
blanching  of  the  tissues.  In  a  few  seconds  there  will 
be  frothing  about  the  needle,  and  in  from  half  a  min- 
ute to  a  minute,  the  hair  will  come  away  upon  the 
very  slightest  traction. 

Such  is  the  operation.  Care  must  be  taken  to  use 
the  negative  pole,  for  otherwise,  instead  of  an  electro- 
lytic action,  a  charring  of  the  tissues  will  result,  and  per- 
manent blackish  spots  will  be  left  in  the  skin.  The 
hair  must  not  be  pulled  on  with  any  force,  for  the  ease 


1?G  DISEASES   OF  THE   HAIR   AND   SCALP. 

with  which  it  leaves  the  follicle  is  a  guarantee  of  the 
completeness  of  the  operation.  The  hairs  must  not  he 
extracted  in  close  proximity,  because  the  inflammatory 
action  thus  set  up  will  lead  to  more  or  less  ulceration 
and  subsequent  prominent  scars.  At  first,  at  least 
some  three -sixteenths  of  an  inch  should  be  left  be- 
tween the  hairs:  later,  when  the  susceptibility  of  the 
skin  is  known,  they  may  be  taken  out  nearer  to  each 
other.  It  is  best  only  to  extract  the  coarser  hau'  and 
to  leave  the  lanugo  hairs  alone.  The  strength  of  the 
current  to  be  used  will  depend  upon  the  qualit}^  of  the 
patient's  skin  and  the  recentness  of  the  filling  of  the 
battery.  Eight  cells  are  the  fewest  I  have  used,  and 
fifteen  the  greatest  number:  that  is,  a  current  of  froii] 
one  half  to  one  and  a  half  milliamperes. 

The  immediate  effect  of  the  operation  is  the  produc- 
tion of  a  number  of  wheals  which  are  evanescent.  On 
the  next  day  only  red  points  are  seen,  and  in  a  few 
days  no  traces  of  the  operation  are  visible,  or  else  min- 
ute cicatricial  points,  when  the  skin  is  examined  with 
the  greatest  care.  In  some  skins,  however,  the  re- 
action is  much  greater.  The  finer  the  needle  is,  the 
less  the  reaction  wiU  be.  The  patient  should  be  di- 
rected to  bathe  the  face  in  Ji of  water  after  the  opera- 
tion, and  to  anoint  it  with  cold  cream.  If  these  direc- 
tions are  carefuUy  carried  out,  and  the  requisite 
skill  in  the  introduction  of  the  needle  is  acquired 
by  practice,  an  absolute  cure  will  be  the  result. 

While  the  just  detailed  operation  is  the  only  one 
which  is  at  all  certain  of  success,  various  other  means 
have  been  tried  to  destroy  superfluous  hair,  and,  for 
completeness,  must  be  given  in  this  place.  Depilatories 
are  of  very  ancient  date,  and  there  are  many  vaunted 
ones  now  in  the  market.  Many  of  my  patients  have 
used  many  kinds.  That  they  have  come  to  be  operated 
on  by  electrolysis  tells  the  tale  of  the  failure  of  depila- 


HYPERTROPHIA   PILORUM.  l77 

tories.  Still,  they  are  useful  in  some  conditions.  When 
the  patient's  hair-growth  is  very  fine  they  may  he  ad- 
vised, as  fine  hair  is  not  so  favorable  for  operation  as 
is  coarse  hair.  When  the  hair-growth  is  partly  fine 
and  partly  coarse  it  is  a  good  plan  to  remove  the  whole 
by  a  depilatory,  and  thus  lighten  our  work,  as  the 
coarse  hairs  will  naturally  appear  first  in  growing,  and 
then  can  be  removed  before  the  fine  hair  obscures  them. 
Depilatories  act  only  on  the  hair  above  the  surface 
and  not  on  the  roots.  Anderson  recommends  one 
composed  as  follows: 


Sulphuret  of  barium, 

. 

3iss=G, 

Oxide  of  zinc. 

, 

3vj=24 

Carmine, 

• 

gr.j=00. 

Some  of  this  powder  is  to  be  mixed  with  enough 
water  to  make  a  paste,  applied  to  the  part  and  washed 
off  in  three  minutes.  Duhring  (10)  gives  the  following 
formula: 

^  Sodii  sulphid,         .         .         .         .        3ij=:8. 
Cretae  preparat,     .         .         .         .     3vj  =  2-I:. 
M. 

This  is  to  be  made  into  a  paste  with  water  and  ap- 
plied as  a  thin  coating,  and  left  on  for  ten  or  fifteen 
minutes.  As  soon  as  it  causes  heat  of  the  skin,  it  is  to 
be  washed  off,  and  the  part  is  to  be  anointed  with  a 
bland  ointment. 

Leonard  (64)  tells  us  that  in  Eastern  harems,  where 
it  is  the  fashion  to  destroy  the  axillary  and  jnibic  hair, 
they  use  a  composition  called  ' '  rusma ' '  made  of 

Arsenici  tersulphuret,         .         .         3  ss=2. 

Calcis, §ss=lG. 

Farinae  tritici,     .         .         .         .       3ij=2.5. 
Aqua3  ferv.  qs.  ut.  ft.  pasta. 
M. 


178  DISEASES   OF   THE   HAIR   AND   SCALP. 

This  is  applied  with  a  wooden  spatula,  to  the  thick- 
ness of  a  knife  blade,  and  left  on  for  from  five  to  ten 
minutes,  or  until  it  begins  to  sting,  when  it  is  scraped 
off  with  a  blunt-edged  knife,  and  the  skin  w^ashed  with 
warm  water  and  dusted  with  rice  or  starch  powder. 
'.  Xeumaxx  (27)  gives  an  extended  list  of  depilatories  in 
his  work  on  the  skin.  All  of  them  require  careful 
watching,  as  it  is  possible  that  their  action  may  go  too 
far. 

Nothing  need  be  said  about  cutting  the  hair,  shav- 
ing it,  and  pulling  it  out  bv  tweezers.  The  most 
ancient  method  of  getting  rid  of  hair  is  by  fire — burn- 
ing it  off. 

C.  Heitzman  (3.14),  in  ISSl,  reported  the  results  of  a 
number  of  experiments  with  hyj^odermic  injections,  the 
hair  being  extracted  and  then  tlie  needle  introduced 
and  the  injection  made.  He  first  tried  the  tincture  of 
iodine,  one  part  in  ten,  and  extracted  fifty  hairs. 
More  than  one  half  returned  in  three  months.  He 
then  used  equal  paiis  of  carbonate  of  potash  and  water. 
Nearly  all  returned.  Then  caustic  potash,  one  to  six 
or  four,  was  injected.  Twenty-four  hairs  were  ex- 
tracted from  his  own  arm  and  in  six  months  only  six 
retm-ned.  He  thinks  that  in  the  strengih  of  one  to 
four  with  a  fresh  solution  it  is  capable  of  destroying- 
hair  under  symptoms  of  suppuration.  The  needle 
should  be  run  obliquely  under  the  skin  and  given  a 
rotatory  motion.  Many  other  attempts  to  destroy  hair 
by  means  of  introducing  needles  dipped  in  various  sub- 
stances into  the  folhcle  have  been  made  with  indiffer- 
ent success.  It  would  seem  that  the  medicament 
would  be  rubbed  off  against  the  walls  of  tlie  upper  part 
of  the  f oUicle  before  it  could  reach  the  papilla,  and  that 
any  good  effected  would  be  due  to  exciting  a  suppura- 
tive action  at  or  near  the  surface  of  the  skin. 

BuLKLEY  (32-1:),  in  1S7S,  reported  several  successful 


J 


HYPERTROPHIA   PILORUM.         •  179 

cases  treated  by  means  of  a  three-cornered  surgical  or 
glover's  needle,  which  was  passed  into  the  follicle  and 
rotated  while  in  the  region  of  the  papilla  so  as  to  break 
up  its  substance.  The  hair  is  to  be  seized  with  the 
epilating  forceps,  put  slightly  on  the  stretch,  and  the 
point  of  the  needle  placed  at  the  niouth  of  the  follicle. 
The  needle  is  to  be  slowly  pressed  in  and  the  hair  pulled 
out  when  the  needle  will  pass  into  the  follicle.  Gener 
ally  no  bleeding  occurs,  and  the  operation  is  not  very 
painful  and  no  scarring  results.  This  is  a  good  method 
of  treatment  where  there  are  only  a  few  hairs  to  be  re- 
moved and  a  galvanic  battery  is  not  at  hand. 


CHAPTEE   X. 

TRICHIASIS  AND  DISTICHIASIS. 

These  diseases  belong  to  the  domain  of  the  opthalmic 
surgeon,  rather  than  to  that  of  the  dermatologist,  but 
they  are  usually  included  in  systematic  treatises  upon 
the  skin,  imder  the  section  upon  Hypei-trichosis.  They 
occur  not  infrequently:  the  last  report,  (1SS6,)  of  the 
Manhattan  Eye  and  Ear  Hospital  showing  20  cases  in 
tl5S  cases  of  diseases  of  the  eyehds. 

Trichiasis  is  a  congenital  or  acquired  misplace- 
ment of  the  ciha,  so  that  they  are  directed  backward 
toward,  and  scratch  upon,  the  globe  of  the  eye;  com- 
bined with  a  growth  of  lanugo  hairs  with  the  same  in- 
clination backwards.  This  condition  is  usually  ac- 
quired, though  there  may  be  some  original  irregularity 
of  the  ciha.  These  are  not  only  misplaced  so  as  to 
point  backward,  but  are  often  twisted  or  distorted. 
As  a  rule  both  the  upper  and  lower  lid  are  affected;  and 
l)oth  eyes  may  be  involved  in  the  disease.  The  lanugo 
hairs  that  are  met  with  develop  after  tlie  distortion  of 
the  ti-ue  ciha  has  existed  for  a  gi'eater  or  less  length  of 
time.  They  gTow  from  every  portion  of  the  tarsal 
margin,  and  even  from  the  mucous  membrane  of  the 
hds. 

This  disease  is  dependent  upon  some  long-continued 
inflammatory  disease  of  the  eyehds,  which  causes  a  dis- 
tortion of  the  lid  and  interference  ^^^th  the  direction 
and  nutrition  of  the  hair-folhcles.  It  therefore  very 
conmionly  foUows  upon  granular  and  puiTdent  opthal- 
mia. 


TRICHIASIS   AND  DISTICHIASIS.  181 

Distichiasis  is  a  congenital  or  acquired  condition  in 
which  the  ciUa  grow  in  two  distinct  rows,  the  inner 
row  being  directed  inwards  so  as  to  impinge  upon  the 
cornea.  It  differs  from  trichiasis  in  an  entire  absence 
of  lanugo  hairs,  the  supernumerary  hairs  being  nor- 
mal ciHa.  Sometimes  the  inner  row  cannot  be  seen 
until  the  lid  is  everted.  The  condition  may  be  pai-tial 
or  complete,  usually  the  former.  According  to  Michel 
(380)  generally  the  outer  third  of  the  upper  lid  is  affect- 
ed alone,  the  deformity  is  symmetrical  and  bilateral,  and 
of  embryonic  origin.  The  second  row  of  cilia  springs 
from  the  flattened  tarsal  margin  near  its  posterior 
edge.  Where  this  arrangement  of  the  cilia  is  not  con- 
genital, it  is  dependent  upon  the  same  causes  as  trich- 
iasis. Both  diseases  cause  irritation  of  the  cornea, 
opacity  of  the  same,  panus,  and  ulceration,  matters 
which  do  not  concern  us  here. 

The  treatment  is  palliative,  as  by  epilation;  or  rad- 
ical, by  operation.  Until  recent  times  the  opthalmic 
surgeon  has  made  a  radical  cure  by  cutting  out  either 
a  piece  of  the  lid  so  as  to  shorten  it  and  somewhat 
evert  it,  or  by  excising  a  part  of  the  tarsal  cartilage 
with  the  offending  hairs.  For  these  matters,  books  on 
the  diseases  of  the  eye  are  to  be  consulted.  To  Michel 
(380),  of  St.  Louis,  is  due  the  credit  of  first  destroying 
the  supernumerary  and  distorted  hairs  by  means  of 
electrolysis.  The  operation  is  the  same  as  is  given  in 
the  preceding  chapter.  Michel  states  his  preference 
for  a  No.  8  cambric  needle,  because  its  action  is  not  so 
limited  as  is  that  of  a  finer  one. 


CHAPTER  XI. 

SYCOSIS. 

Derivation. — Gr.  ovnooai^,  a  Fig. 

Synonyms. — Sycosis  non  parasitica;  Sycosis  menti; 
Sycosis  barbce  (Celsus) ;  Mentagra  (Plenck)  ;  Acne 
mentagra;  Folliculitis  barbce  (Kobner);  Folliculitis  pi- 
loruni;  Herpes  pustulosus  mentagra  (Alibert);  Lichen 
menti ;  Acne  sycosis  (Morris) ;  Coccogenous  sycosis 
(Unna);  Fr. ;  Sycosis  non  parasitaire;  Dartre  pustu- 
leuse  mentagra;  Adenotrichie  (Hardy);  Ger. :  Bart- 
finne,  Bartflechte,  Fikosis;  Eng:  Barber's  itch. 

Definition. — A  chronic  follicular  and  peri- follicular 
inflanmiation  of  the  long,  hau's,  chiefly  affecting  the 
bearded  portions  of  the  face;  characterized  by  an 
eiTiption  of  papules,  pustules,  and  nodules  perforated 
by  hairs;  by  the  formation  of  infiltrated  patches;  and 
by  a  gTeater  or  less  amount  of  crusting. 

Symptoms. — It  is  only  of  comparatively  recent  years 
that  tliis  disease  has  been  recognized  as  a  separate  en- 
tity, and  it  is  stiU  regarded  by  some  authorities  as  merely 
a  form  of  eczema.  But  the  expei'ience  of  the  major- 
ity of  dermatologists  has  taught  them,  that  the  disease 
is  quite  independent  of  either  eczema  or  trichophytosis 
barbae.  The  disease  begins  by  the  formation  of  a  num- 
ber of  red  inflammatory  papules  and  nodules,  which 
are  more  or  less  conical,  usually  raised  above  the  sur- 
face of  the  skin  and  always  perforated  by  hairs.  Their 
appearance  is  preceded  and  accompanied  by  disagi'ee- 
able  local  sensations,  such  as  pricking,  burning,  and 
smarting,  and  at  times  by  a  feeling  of  tension  in  the 
part,  on  account  of   sweUing  of   the  skin.     In  acute 


SYCOSIS. 


183 


cases  there  is  considerable  redness  of  the  skin  between 
the  papules,  and  the  inflammation  may  be  so  intense 
as  to  give  rise  to  enlargement  of  the  neighboring  lym- 
phatic glands.  The  papules  and  nodules  vary  in  size, 
from  that  of  a  millet  seed  to  that  of  a  pea,  and  are  iso- 
lated or  grouped,  not  every  hair-follicle  in  a  diseased 
part  being  affected  by  the  peri-foUicular  inflammation. 


Sycosis. 

Only  in  very  severe  outbreaks  or  in  acute  exacerba- 
tions do  the  papules  and  tubercles  tend  to  run  together 
and  form  infiltrated  patches. 

The  papules  and  nodules  soon  change  into  pustules, 
which  preserve  the  same  characteristics  of  grouping 
and  are  likewise  always  pierced  by  hairs.  These  pus- 
tules, conical  in  shape  and  perforated  by  hairs",  are 
pathognomonic  of  the  disease.  In  old  cases  they  are 
met  with  in  the  infiltrated  patches,  arising  apparen^^ly 


184  DISEASES   OF   THE   HAIR  AND   SCALP. 

without  the  preceding  appearance  of  papules  and 
nodules.  The  pustules  show  no  tendency  to  rupture, 
but  the  pus  accumulates  below,  wells  up  alongside  of 
the  hair,  appears  upon  the  surface  of  the  skin  and 
dries  into  thin  crusts.  The  amount  of  crusting  is  never 
very  great,  far  less  than  in  eczema  of  the  beard,  and 
is  appreciable  mainly  when  the  beard  is  growing.  If 
the  crusts  are  removed  from  a  well-developed  patch, 
the  skin  looks  as  if  pitted,  with  the  hairs  standing  in 
the  pits.  If  the  inflammation  is  very  intense,  we  may 
meet  with  small  cutaneous  abscesses  here  and  there, 
instead  of  pustules.  According  to  A.  R.  Eobinson  (33) 
the  amount  of  pus  j^roduction  varies  with  the  indi- 
vidual attacked,  being  more  rapid  and  abundant  in 
the  robust  than  in  the  scrofulous;  in  acute  than  in 
chronic  cases. 

The  hair,  if  of  any  length,  is  early  affected  in  appear- 
ance, becoming  lustreless.  It  is  at  first  firmly  seated 
in  its  follicles,  and  when  puUed  upon  gives  rise  to  pain, 
and  if  extracted  its  root-sheath  will  appear  as  a  clear 
glassy  cylinder.  Later,  as  pus  forms  more  abundantly 
in  the  peri- follicular  tissues,  and  the  follicles  themselves 
are  involved  in  the  process,  the  hair  becomes  loosened 
and  easily  extracted,  when  its  root -sheath  wiU  be  found 
swollen  with  pus.  If  the  pus  j^roduction  is  excessive, 
the  hairs  will  fall  of  themselves  or  upon  the  slightest 
traction.  When  this  occurs  the  hair  papilla  may  be  so 
damaged  that  no  new  hairs  will  form.  In  chronic 
cases  the  beard  is  markedly  thinned,  though  perma- 
nent loss  of  hair  is  the  exception. 

The  disease  may  attack  any  part  of  the  bearded  face, 
and  may  be  met  with  in  other  hairy  regions,  as  the 
neck,  the  eyebrows,  scalji,  axilla,  and  pubes.  But 
the  beard  is  by  far  most  often  the  site  of  the  disease, 
the  other  situations  being  affected  in  the  order  in 
Vvdiich  they  are  named.    Occurring  in  the  beard,  it  may 


SYCOSIS.  185 

be  limited  to  a  single  region  and  show  no  tendency  to 
spread.  Thus,  it  is  met  with  very  frequently  upon  the 
upper  lip  alone,  or  at  times  only  upon  the  chin.  It 
may  attack  the  whole  bearded  face  in  an  acute  out- 
break, or  it  may  involve  it  by  extension  from  a  limited 
area  during  a  number  of  successive  outbreaks.  In 
chronic  cases  it  is  usually  symmetrical.  The  course  of 
the  disease  is  chronic  and  made  up  of  a  number  of 
acute  exacerbations.  If  left  to  itself  it  may  produce 
a  good  deal  of  deformity,  the  tubercles  and  pustules 
breaking  down,  ulcerating,  and  leaving  cicatrical  tis- 
sue and  more  or  less  baldness. 

A  typical  case  of  sycosis  presents  the  following  ap- 
pearances. Upon  a  single  region,  two  or  more  regions, 
or  upon  the  whole  bearded  portion  of  the  face,  there 
will  appear  a  number  of  isolated  or  grouped  papules, 
nodules  or  pustules  pierced  by  hairs.  The  skin  about 
the  lesions  is  reddened  and  swollen,  it  may  be  indu- 
rated, and  there  is  a  slight  amount  of  crusting.  There 
is  no  tendency  for  the  disease  to  spread  to  non-hairy 
parts,  but  very  commonly  the  eyebrows  will  be  simi- 
larly affected,  and  a  blepharitis  will  be  present.  In 
some  chronic  cases  there  will  be  much  loss  of  hair 
and  some  scarring,  and  perhaps  few  pustules,  but  a 
red,  thickened,  slightly  scaly  skin. 

When  the  case  is  watched  for  a  time,  marked  ex- 
acerbations will  arise,  often  without  apparent  cause, 
last  for  a  few  days,  and  then  the  disease  will  sink  into 
a  subacute  condition. 

When  the  disease  affects  the  vibrissae  of  the  nose,  by 
extension  from  the  upper  lip,  the  Schneiderian  mem- 
brane becomes  swollen  and  exquisitely  sensitive. 

Etiology. — The  etiology  of  the  disease  is  not  settled. 
Statistical  tables  show  that  it  occurs  about  six  times 
in  every  thousand  cases  of  skin  diseases.  It  probably 
occurs  more  often  than  this,  as  some   cases  recovf^r 


ISO  DISEASES   OF  THE   HAIR  AND   SCALP. 

rapidly  under  domestic  treatment  or  even  when  left 
alone.  It  is  non-contagious.  Unxa  (312  ap.)  and 
some  others  believe  that  the  disease  is  due  to  the 
entrance  of  pus  cocci  into  the  hair-follicles.  It  is  seen 
in  men  almost  exclusively,  as  we  might  expect,  and 
attacks  them  most  frequently  between  the  ages  of 
twenty -five  and  fifty.  Both  the  well  nourished  and 
the  poorly  nourished,  the  rich  and  the  poor,  suffer 
from  it.  I  have  seen  it  very  frequently  in  tailors,  and 
in  them  it  has  proved  very  obstinate.  Eczema  is  often 
a  forerunner  of  sycosis,  the  one  process  passing  over 
into  the  other.  A  nasal  catarrh  is  the  cause  of  the 
majority  of  cases  occurring  on  the  upper  lip.  Shaving 
with  a  dull  razor  against  a  stiff  beard  is  sometimes  an 
exciting  cause,  though  those  who  do  not  shave  are  by 
no  means  exempt  from  the  disease.  An  irritant  ap- 
plied to  the  skin  may  excite  it,  such  as  exposure  to 
hitense  heat,  the  dust  of  a  workshop,  cosmetics  and  the 
like.  Exposure  to  inclement  weather  is  regarded  by 
AViLSON  (38)  as  the  principal  cause.  One  of  the  worst 
cases  I  have  ever  met  with  was  directly  traceable  to  a 
poultice  applied  to  the  face  for  the  relief  of  a  neuralgia. 

Given  a  hypersemic  or  irritable  condition  of  the  skin 
of  the  face  arising  from  any  internal  or  external  cause, 
the  hairs,  especiaUy  if  they  are  coarse,  may  excite  the 
disease,  acting  as  irritants  when  touched  or  moved. 
Hebka  ( 3i>4)  thinks  that  some  cases  may  be  due  to  an  ab- 
normality in  the  growth  of  new  hairs.  Wertheim  as- 
cribed the  inflammation  to  irritation  of  the  hair-foUi- 
cles  by  hairs  whose  diameter  was  relatively  too  large 
for  their  follicles. 

Pathology. — A.  E.  Eobinsox  (400)  w^ho  has  made  ai 
exhaustive  study  of  the  pathological  anatomy  of  thi 
disease,  teaches  us  that  it  is  "  primarily  a  peri-foUiculi 
inflammation  of  the  skin.  The  first  changes  whicl 
take  place  occur  around  the  follicle  in  the  x^eri-foUici 


SYCOSIS.  IST 

lar  region,  and  are  those  which  are  usually  observed  in 
vascular  connective-tissue  inflammations.  The  trans- 
uded serum  penetrates  the  hair-follicle,  and  as  the  in- 
flammation proceeds  and  the  pus  and  serum  increase 
in  quantity,  the  follicle  becomes  more  and  more  affected. 
Its  sheaths  become  softened  and  more  or  less  destroyed, 
and  a  portion  of  the  pus  may  enter  tlie  follicle  through 
the  ruptured  sheaths.  The  cells  of  the  external  root- 
sheath  become  swollen  and  soon  begin  to  break  down; 
similar  changes  occur  in  the  cells  of  the  hair-root:  they 
swell,  the  protoplasm  becomes  more  granular  in  ap- 
pearance, and  there  is  evidence  of  commencing  destruc- 
tion. After  the  rupture  of  the  follicle-sheaths,  or  even 
before,  the  cells  of  the  hair-root  and  of  the  root-sheaths 
rapidly  become  broken  np  and  changed  by  the  trans- 
uded serum  entering  the  follicle.  If  pus  corpuscles 
have  also  entered  the  follicle,  the  hair- root  is  infiltrated 
with  a  sero-purulent  matter;  it  does  not  in  every  case 
enter  it  in  large  amount.  In  the  i)ustular  stage  the 
principal  changes  take  place  within  the  follicle;  the 
hair-root  and  its  sheaths  are  broken  down  and  separated 
from  the  follicle  sheaths,  so  that  the  hair  lies  loosely 
within  the  follicle. 

' '  As  the  inflammation  progresses,  the  connective- 
tissue  around  the  follicle  becomes  crowded  with  pus 
ceUs,  as  far  as  the  surface  of  the  skin.  If  the  hair  is 
allowed  to  remain  within  the  follicle  until  expelled  by 
the  accumulating  pus,  the  root-sheaths  and  soft  parts 
of  the  hair  are  destroyed,  and  only  the  hard  part  re- 
mains. The  folhcle-sheath,  and  the  peri-follicular  tis- 
sue are  more  or  less  destroyed,  and  the  Malpighian  layer 
becomes  ruptured  at  the  neck  of  the  follicle.  The  pus 
reaches  the  surface  by  breaking  through  the  epidermis 
near  the  hair;  some  passes  to  the  surface  between  the 
hair-shaft  and  the  follicle -sheath.  The  cells  from 
which  the  hair  grows  seem  to  resist  the  inflammatory^ 


18$  DISEASES   OF   THE   HAIR  AND   SCALP. 

process  more  than  the  other  cells  of  the  bulb.  When 
permanent  alopecia  results  both  the  follicle-sheaths  and 
the  base  of  the  follicle  are  completely  destroyed.  If 
eczema  is  present  the  root-sheaths  and  follicle-sheaths 
are  acted  upon  in  their  entire  length  at  the  same  time. 

' '  The  sebaceous  glands  may  also  become  affected, 
though  not  at  so  early  a  stage  of  the  disease  as  the  fun- 
dus of  the  hair,  and  the  whole  gland  may  be  destroyed 
by  a  process  of  molecular  retrograde  degeneration. 
The  sweat  glands  generally  escape,  but  the  epithelial 
cells  may  become  detached  or  the  glands  destroyed. " 

GiovANNiNi  (86  ap.)  has  found  the  affected  hairs 
thicker  than  normal,  with  more  or  less  notched  con- 
tour, so  that  the  hair  presents  from  two  to  six  irregu- 
lar projections.  In  the  middle  of  the  hairs  he  has 
found  broad  and  irregular  cavities  filled  with  pigment, 
fat,  and  detritus.  Unna  (312  ap.)  teaches  that  sycosis 
may  be  caused  by  the  common  pus  cocci  gaining  access 
to  the  hair  follicles  by  traumatism  or  mechanical  fric- 
tion. The  hair  remains  unaltered  for  some  time  after 
the  invasion  of  the  follicle.  Any  pustular  inflamma- 
tion may  start  this  form  of  sycosis.  Tommasoli  (311 
ap.)  describes  a  bacillary  f orm  due  to  short,  rod-shaped, 
somewhat  tliick,  and  elliptical  bacilli  with  rounded 
ends,  the  bacillus  sycosiferus  foetidus.  This  he  be- 
lieves to  be  of  tubercular  nature. 

Diagnosis. — The  distinguishing  characteristic  of  sy- 
cosis is  the  presence  of  pustules  pierced  by  hairs.  It 
must  be  diagnosed  from  trichophytosis  barbae,  eczema 
barbae,  the  small  pustular  syphiloderm,  acne,  and  lupus. 

Differential  diagnosis  from  trichophytosis  barbae  : 


SYCOSIS. 


189 


Trichophytosis  harhm, 
Begins  as  a  small  scalj'^  spot, 
a    superficial     ring-worin,     and 
gradually  involves  the    deeper 
parts  of  the  hair. 

Has  its  favorite  seat  upon  the 
chin  and  the  sub-maxillary  re- 
gion ;  rarely  attacks  the  upper 
lip.     Often  asymmetrical. 

The  eruption  consists  of  tuber- 
cles and  nodules  which  tend  to 
group  and  are  studded  with  a 
number  of  hairs.  The  inter- 
nodular  portions  of  the  skin  of- 
ten remain  unaffected. 


Is  a  deep  inflammatory  pro- 
cess as  soon  as  the  hairs  become 
affected. 

Hair  is  diseased  primarilj'-,  and 
is  twisted,  split  and  broken. 

May  readily  be  removed  by 
slight  traction  and  without  pain. 
Its  root  is  often  dry. 

Subjective  symptoms  slight, 
may  be  only  slight  pruritus. 


Patches  of  ringworm  often 
present  on  other  parts  of  the 
body,  and  sometimes  the  dis- 
ease extends  upon  the  neck  or 
face. 

Hairs  and  scales  loaded  with 
the  tricophyton  fungus. 

Is  a  progressive  disease,  and 
when  cured  not  liable  to  relapse. 


Sycosis. 

Begins  siiddenl}'-  with  an  out- 
break of  papules  which  soon  be- 
come pustules,  each  of  which  at 
the  start  involves  a  hair. 

Its  favorite  seat  is  the  upper 
lip,  and  sometimes  it  alone  is  in- 
volved. Involves  the  hairy  por- 
tions of  the  face  more  generally 
and  often  symmetrically'. 

The  eruption  consists  of  pa- 
pules and  pustules,  each  of 
which  is  pierced  by  a  single 
hair,  and  they  show  no  disposi- 
tion to  group.  The  intervening- 
skin  is  generally  reddened,  and 
maj'  be  diffusely  infiltrated  ;  and 
abcesses  may  form. 

Is  a  more  superficial  inflam- 
mation. 

Hair  diseased  secondarih'  and 
comes  away  at  first  with  difli- 
culty,  causing  much  pain.  Later 
is  easily  removed  and  its  root  is 
swollen  with  pus. 

Subjective  symptoms  of  prick- 
ing, burning,  and  tension  of  the 
part.  These  are  often  intense 
and  attended  with  swelling  of 
the  face. 

Limited  in  most  cases  to  hairy 
parts  of  the  face.  No  tendency 
to  extend  on  non-hairy  parts  of 
face  or  neck. 

No  fungus  present. 

The  course  of  the  disease  made 
up  of  a  number  of  acute  out- 
breaks.    Liable  to  relapse. 

The  differential  diagnosis  from  eczema  of  the  beard 
cannot  be  made  with  so  much  certitude,  and  often  we 
must  remain  for  a  while  in  doubt  as  to  the  true  nature 
of  the  case.  At  times  the  sycosis  is  a  legacy  left  by  a 
preceding  eczema,  and  we  may  meet  with  a  case  in 
the  transition  stage  when  a  sure  diagnosis  would, 
manifestly,  be  impossible.  A  typical  case  of  pustular 
eczema  is  attended  by  a  far  greater  amount  of  crust- 
hig  than  is  sycosis,  and  the  crust  is  of  a  more  greenish 
or  blackish  color.     Ui^on  removing  the  crust  in  eczema 


190  DISEASES   OF   THE   HAIR  AND   SCALP. 

a  moist  and  oozing  surface  will  be  exposed,  while  in 
sycosis  we  will  do  no  more  than  remove  the  tops  from 
a  number  of  pustules.  In  eczema  the  pustules  break 
down  more  readily  than  in  sycosis,  and  they  are  not 
so  accurately  located  about  the  hairs.  In  eczema  the 
whole  sui-face  of  the  skin  is  involved  and  the  process 
tends  to  extend  upon  non-hairy  parts  of  the  face.  While 
exceptionally  eczema  is  confined  to  the  hairy  portions 
of  the  face  this  is  always  so  in  sycosis.  The  duration 
of  the  disease  will  at  times  help  us  to  a  diagnosis,  sy- 
cosis being  far  more  chronic  than  is  eczema. 

In  syphilis  when  the  beard  is  involved  we  will  find 
pustules  upon  other  portions  of  the  body,  and  the  his- 
tory will  help  us  to  a  correct  conclusion.  The  pustules 
or  papules  of  syphilis  are  gi'ouped  in  circles  or  segments 
of  circles,  of  peculiar  color,  and  their  development  is 
painless  and  comparatively  slow.  Pustalar  sypliihs 
more  often  causes  permanent  baldness  than  does 
sycosis. 

Acne  is  scattered  about  the  whole  face,  is  usually 
met  with  in  young  persons,  comedones  are  present  and 
its  papules,  pustules,  or  tubercles  have  no  definite  re- 
lation to  the  hair. 

The  course  and  history  of  lupus  are  so  different 
from  tliat  of  S3"cosis,  that  it  is  hardly  possible  for 
them  to  be  confused.  In  lupus  vulgaris  we  have 
the  characteristic  brown  tubercles  which  do  not 
contain  pus,  are  not  confined  to  the  hairy  poii^ions  of 
the  face,  generally  begin  in  early  hfe,  and  tend  to  ul- 
cerate or  to  be  absorbed  and  leave  behind  cicatrices. 

Treatment. — The  treatment  of  sycosis  is  both  gene- 
ral and  local.  While  many  cases  will  yield  to  local 
treatment  alone,  there  are  quite  as  many,  if  not  more, 
which  require  general  treatment.  The  surroundings 
of  the  patient  must  be  inquired  into,  and  also  his  mode 
of  hfe.     He  should  be  urged  to  take  exercise  in  the 


SYCOSIS.  Iftl 

daylight;  a  powerful  means  for  good  if  the  case  hap^ 
pen  to  fall  upon  one  constantly  employed  in  badly  ven- 
tilated rooms,  such  as  tailors  and  the  like.  He  should 
be  advised  against  exposing  himself  to  dust  and  wind, 
and  even  against  smoking,  especially  in  the  wind  where 
the  smoke  blows  against  the  face.  The  proper  regula- 
tion of  the  diet  is  important.  Many  cases  will  improve 
if  we  stop  their  tea,  coffee,  hot  drinks  of  all  sorts,  ale, 
beer,  and  spirits.  If  the  digestive  process  seem  at  all 
embarrassed,  it  is  well  to  put  the  patient  on  a  light 
diet  for  morning  and  evening,  and  direct  him  to  take 
his  principal  meal  at  noon,  eating  meat  only  at  that 
time.  Anything  that  is  known  to  him  to  be  indigesti- 
ble must  of  course  be  prohibited.  In  a  word  the  diet 
and  hygiene  of  the  patient  should  be  regulated. 

What  medicines  we  should  administer  wiU  depend 
upon  the  stage  of  the  disease.  In  the  acute  stage,  when 
there  is  much  swelHng  and  inflammation,  a  good  dose 
of  blue  pill,  calomel,  or  some  other  active  cathaiiic  is 
to  be  ordered,  to  be  foUowed  by  an  alkahne  diuretic. 
When  pustulation  is  active  the  sulphide  of  calcium  or 
calx  sulphurata  will  do  good.  Piffard  (399)  recom- 
mends this  very  highly,  giving  one-tenth  of  a  grain 
two  or  three  times  a  day.  Care  must  be  exercised  that 
our  patient  obtain  the  drug  fresh.  I  have  found  the 
exhibition  of  the  drug  in  the  form  of  the  tablet  tritu- 
rate by  far  the  most  active  way.  Small  doses  of  calo- 
mel, as  one-tenth  of  a  grain  three  times  a  day  for  two 
or  three  days  at  a  time,  are  useful  in  relieving  the 
congestion  of  the  skin.  In  chronic  cases,  iron,  cod- 
liver  oil,  and  other  tonics  are  indicated  if  there  is  a 
state  of  debility.  Arsenic  is  advised  in  very  obstinate 
cases.  If  indigestion  is  present  we  must  address  our 
remedies  to  its  relief  before  we  give  calcium,  arsenic, 
or  other  remedy  for  the  disease  proper. 


192  DISEASES   OF   THE   HAIR  AND   SCALP. 

The  local  treatment  is  more  important  than  the  gen- 
eral, and  is  required  in  every  case.  It  must  vary  vrith 
the  condition  found,  whether  it  be  acute  or  sub -acute. 
When  the  disease  attacks  the  upper  lip  the  nose  must 
be  examined  for  evidences  of  catarrh^  and  that  condi- 
tion treated  if  found.  I  have  had,  at  times,  good  re- 
sults from  the  subnitrate  of  bismuth  or  powdered  cu- 
bebs,  used  as  a  snuff  in  this  condition,  but  it  is  best 
for  each  physician  to  use  for  this,  that  which  experi- 
ence has  taught  him  to  be  most  useful. 

In  the  management  of  an  acute  case  of  sycosis  sooth- 
ing remedies  are  needed.  Hot  water  should  be  soj^ped 
on  the  part  for  some  five  or  ten  minutes  once  or  twice 
a  day,  and  this  should  be  followed,  if  the  beard  is  grow- 
ing,  by  the  use  of  a  simple  oil  such  as  olive  oil  or  sweet 
almond  oil,  or  if  the  face  is  shaved  the  zinc  oxide  oint- 
ment or  cold  cream  may  be  used;  or  better  stiU,  Las- 
sar's  paste,  as  foUows: 

Amyli, 

Zinci  oxidi.      aa    .         .         .         .3  ij — 8. 
VaseHne,         ad    .         .        .         »      5  j  — 32 
M. 

Powdering  the  part  with  corn  starch,  or  bismuth  and 
talc,  after  smearing  on  a  little  vaseline,  wiU  at  times 
give  ease  and  comfoi-t.  If  the  i^rocess  is  attended 
by  a  good  deal  of  oedema  and  the  inflammatory 
symptoms  are  severe,  warm  poultices  wiU  relieve  the 
disagreeable  sensations  of  the  patient  and  reduce  the 
inflammation.  In  some  cases  cold  starch  poultices  wiU 
be  better  borne.  Devergie  (387)  recommends  steam- 
ing the  inflamed  parts  every  second  day,  and  covering 
the  affected  parts  constantly  with  cold  or  almost  cold 
thin  flaxseed  poultices.  Even  in  the  early  stage,  if  the 
inflammatory  symf)toms  are  not  very  intense,  a  mild 
white  precipitate  ointment  wiU  sometimes  check  the 


Sycosis.  i93 

disease.  Duhrixg  (10)  recommends  bathing  the  face 
with  "  black  wash  "  followed  by  zinc  oxide  ointment 
with  a  drachm  of  alcohol  or  half  a  drachm  of  camphor 
to  the  ounce,  spread  on  cloths  and  bound  on  ;  and 
speaks  well  of  the  oxide  of  zinc  ointment  with  fifteen 
to  thirty  grains  of  calomel  to  the  ounce.  Tumenol  oil 
has  yielded  surprising  results  in  some  cases.  The  chief 
objection  to  it  is  its  color.  It  may  be  used  pure  or 
diluted  with  vaseline  or  other  oil.  When  the  disease 
has  reached  the  pustular  stage,  and  there  is  more  or 
less  crusting,  the  crusts  are  to  be  removed  by  the  free 
use  of  olive  oil,  or  oil  of  sweet  almonds,  letting  it  soak 
in  thoroughly  over  night  and  washing  the  part  with 
soap  and  warm  water  the  next  morning.  If  the 
crusts  are  thick,  it  is  a  good  plan  to  tie  up  the  bearded 
face  in  a  towel  after  anointing  it  with  oil.  A  poultice 
may  be  used  for  the  purpose  of  removing  the  crusts. 
After  the  crusts  are  gotten  rid  of,  puU  the  hairs  out  of 
the  pustules,  and  insist  upon  the  patient  shaving  him- 
self every  second  day.  At  first  he  may  rebel  against 
the  use  of  the  razor,  but  if  plenty  of  warm  water  and 
soap  is  used,  and  a  good  lather  formed,  the  shaving 
wiU  not  be  very  painful,  and  it  is  only  the  first  shave 
that  is  painful.  Epilation  of  the  hair  from  all  the  pus 
tules  and  papules  is  to  be  continued  until  they  cease  to 
form.  Shaving  is  to  be  continued  until  some  months 
after  the  skin  is  apparently  well.  It  is  ])ossible  to  cure 
a  case  without  shaving,  but  the  cure  will  be  more  diffi- 
cult to  effect.  The  patient  must  be  made  to  under 
stand  that  epilation  is  necessary,  both  for  the  cure  of 
the  affection  and  the  salvation  of  the  hair.  After  epi- 
latingjthe  oxide  of  zinc  ointment,  Lassar's  paste,  or 
diachylon  ointment  is  to  be  used.  Sulphur  in  the  form 
of  an  ointment,  half  a  drachm  to  a  drachm  to  the  ounce, 
or  in  powder,  will  sometimes  do  good,  but  often  will 
prove  too  irritating.  Tilbury  Fox  (390)  recommends 
the  use  of  the  following  ointment  after  shaving: 


TJi  DISEASES   OF   THK   HAIR   AND   SCALP. 

Zinc  oxide, 

Zinc  carbonate  aa        .         .         .        3  j —  4. 
Hose  ointment  ad        .         .         .        3] — 32. 
M. 

Instead  of  an  ointment  we  may  use  oxide  of  zinc  one 
drachtn  to  the  ounce  of  linseed  or  other  oil.  Shoe- 
maker (i02)  advises  the  api>lication  of  equal  parts  of 
oleate  of  mercury  and  olive  oil. 

In  sub-acate  and  chronic  cases  a  more  active  treat- 
ment is  necessary.  Here  our  aim  is  not  so  much  to 
allay  inflammation  as  to  stimulate  the  skin.  To  this 
end  we  may  use  the  soap  and  salve  treatment  of  Hebra, 
which  renders  such  good  service  in  chronic  cases  of  ec- 
zema. It  consists  of  frictions  with  green  soap,  soft 
soap,  or  better  the  tincture  of  green  soap,  composed  of 
two  parts  of  the  soap  and  one  part  of  alcohol,  followed 
by  a  soothing  ointment,  such  as  the  oxide  of  zinc  oint- 
ment. Some  of  the  soap  is  poured  or  placed  upon  a 
piece  of  flannel,  this  dipped  in  hot  water,  and  then 
rubbed  actively  upon  the  part  to  remove  all  the  tops 
of  the  pustules  or  papules,  and  leave  the  surface  a  lit- 
tle raw.  Then  the  soap  is  aU  washed  off,  and  the  part 
covered  with  the  ointment  spread  thickly  upon  old 
linen  or  cheese-cloth.  The  dressing  is  firmly  bomid 
down  with  a  roUer  bandage.  The  ointment  is  to  be 
changed  two  or  three  times  a  day,  but  the  soap  is  to 
be  used  but  once  a  day  or  every  other  day.  In  some 
cases  better  results  wiU  be  attained  by  the  use  of  di- 
achylon ointment,  or  Lassar's  paste,  with  ten  or  fif- 
teen grains  of  salicylic  acid  to  tJie  ounce.  In  very  ob- 
stinate cases  where  there  is  much  thickening  of  the 
skin,  the  soap  may  be  kept  applied  to  the  part  like  an 
ointment.  When  sufficient  inflammatory  reaction  is 
produced,  emollient  measures,  as  in  the  acute  stage, 
should  be  used.  The  use  of  a  strong  tincture  of  tar 
after  Pick's  formula  of  forty  parts  of  tar  and  twenty 


SYCOSIS.  195 

parts  of  alcohol  sometimes  answers  well.  In  some 
cases  where  there  is  a  good  deal  of  pustulation  and 
the  patient  is  shaven,  it  is  a  good  plan  to  curette  the 
patches,  tearing  off  the  tops  of  the  pustules  and  letting 
out  the  pus.  This  procedure  is  to  he  followed  by  the 
application  of  Lassar's  paste  with  salicylic  acid. 

Our  success  in  treating  these  cases,  will  vary  with 
the  thoroughness  with  which  the  dressings  are  applied. 
All  ointments  must  be  spread  on  cloths,  not  on  the  skin, 
and  the  dressings  must  be  kept  continuously  in  close 
contact  with  the  affected  part.  Sometimes  a  sulphur 
ointment,  one  half  a  drachm  to  two  drachms  to  the 
ounce;  an  ointment  of  iodide  of  sulphur;  the  ointment 
of  the  ammoniate  (gr.  xv-xxx.  ad  3  j),  or  the  red 
oxide  (gr.  v-xv.  ad  3  j)  of  mercury  will  prove  useful. 
Robinson  (33)  recommends  the  following  ointment: 

Ungt.  diachyli  (Hebra) 

Ungt.  zinci  oxidi,  .        .  aa  3  iss — 50. 

Ungt.  hydrarg.  ammon.       .  3  iij — 10. 

Bismuth  subnitrat.        .        .         3  iss —  5. 

M. 

He  has  found  cod-hver  oil  the  best  local  application 
in  strumous  subjects.  Veiel  (10)"  advises  painting  the 
affected  parts  twice  a  day  with  a  two  per  cent,  solu- 
tion of  pyrogallol  in  alcohol,  and  applying  during  the 
night: 

Sulphur,  lact.         .        .        . 

Alcohol, 

Aquee  rosae aa  30. 

Mucilag.  gum  acacise,  .         .  tti  xx-xxxx. 

M. 

Hans  von  Hebra's  (394)  plan  of  treatment  is  to  epilate 
and  shave,  and  then  with  a  stiff  brush  to  rub  in  once 
or  twice  a  day  some  of  the  following  ointment : 

*  Ziemssen's  Handbuch  des  Speciellen  Path.  u.  Therap.  p.  235. 


19(3  DISEASES  OF  THE  HAIR  AND   SCALP. 

01.  fagi, 

Flor.  sulpli., aa  10. 

Pulv.  cretse  alb.,    .        .        .        .  5. 

Adeps, 

Sapo.  viridis.,         .         .         .         .    aa  20. 
M. 
and  cover  with  flannel.     Devergie  (387)  recommends 
painting  the  part  every  fourth  or  fifth  day  with  a  so- 
lution of  nitrate  of  silver,  one  part,  in  five  of  water  by 
weight. 

Behrend  (12)  has  obtained  good  results  by  scraping 
the  affected  parts  with  the  dermal  curette,  and  dressing 
with  a  simple  ointment  or  oil.  All  abscesses  must  be 
opened.  Brooke  (205  ap.)  recommends  the  applica- 
tion, after  epilation,  of  an  ointment  of 

^  Hydrarg.  oleat.  (2 J  per  cent),  .  "f,  i. 

Ichthyol.  s.  amnion.,        .         .         .  tt[  xx. 

Ac.  salicyL,      .         .         .         .         .  gr.  x. 

01.  lavandulae,         ....  gtt.ij. 
M. 

which  is  to  be  kept  applied  on  strijjs  of  linen,  or  mixed 
with  enough  zinc  oxide  and  Armenian  bole  to  make  a 
skin-colored  paste,  and  smeared  on. 

Our  rule  of  treatment  then  is  in  acute  cases  to  aUay 
inflammation  by  emollient  dressings;  in  chronic  cases 
to  stimulate.  In  all  cases  to  epilate,  at  least  from  pus- 
tules, and  where  possible  to  have  the  patient  shave. 
The  dry  and  reddened  skin  sometimes  left  after  the 
disease  has  run  its  course  is  to  be  treated  with  hot 
water  sopped  on  for  five  minutes  once  or  twice  a  day, 
and  some  simple  ointment  to  protect  the  skin  from 
dust  and  exposure  to  the  weather. 

Sycosis  affecting  other  locations  than  the  beard  is 
to  be  treated  by  epilation  and  emollient  ointments. 
When  the  hairs  within  the  nose  are  affected  Harda- 


FOLLICULITIS   DEC  A  L  VANS.  197 

WAY  (299  ap.)  Jias  found  the  best  plan  of  treatment  to 
be  to  foment  the  parts  several  times  a  day,  to  apply 
glycerin  both  to  the  inside  and  outside  of  the  nose, 
and  to  pluck  the  hair  from  the  follicles.  When  pain 
and  tension  have  subsided  he  uses  the  following: 
5  Squire's  glycerol,  plumb,  sub- 

acetat., 3  ss.  2. 

Glycerin., 3iss.  6. 

Ungt.  aqua3  rosae,     .        .        .      1  i.  32. 

Cera3  albee,         .        .        .        .    q.  s. 
M. 

Prognosis. — This  is  one  of  the  most  obstinate  of  dis- 
eases, specially  in  such  cases  as  are  due  to  occupation. 
Left  to  itself,  when  once  under  headway,  it  sliows  no 
tendency  to  get  well,  and  has  been  known  to  last 
twenty  or  thirty  years.  Even  under  the  most  judi- 
cious treatment  it  is  an  obstinate  disease,  taking  weeks 
or  months  before  a  cure  is  effected.  Eelapses  are  ex- 
ceedingly liable  to  occur,  and  these  sometimes  show  a 
disposition  to  recur  at  certain  seasons.  Unless  the  hair 
is  carefully  withdrawn  from  the  inflamed  follicles  per- 
manent baldness  may  be  caused.  But  the  disease  is 
not  dangerous  to  life,  and  it  is  curable. 

FOLLICULITIS   DECALVANS. 

Within  the  past  few  years  there  has  been  described 
by  French  writers  a  group  of  diseases  of  hairy  parts 
that  is  characterized  by,  1,  a  follicular  and  perifolli- 
cular inflammatory  process  ;  2,  a  complete  destruction 
of  the  hair-papillae,  causing  absolute  baldness  ;  3,  the 
f  rmation  of  apparently  cicatricial  tissue  ;  and  4,  a 
tendency  of  the  lesions  to  agminate  or  group.  This 
group  of  diseases  has  been  named  by  Brocq  ' '  follicu- 
litis et  perifolliculitis  decalvans." 


198  DISEASES   OF   THE   HAIR   AND   SCALP. 

The  disease  has  been  described  under  many  names 
apphed  by  different  observers  to  different  phases  or 
locations  of  the  malady.  It  has  been  called  "  lupoid 
sycosis"  by  Milton;  '^alopecie  cicatricielle  innomi- 
nee "  and  ''acne  pilaire  cicatricielle depilante"  by  Bes- 
nier;  ''foUiculite  epilante"  by  Quinquaud;  "Acne 
decalvante"  by  Lailler  and  Eobert;  ''Ulerythema 
sycosiforme "  by  Unna  ;  sycosis  chronique.  Brocq 
would  also  include  under  it  Kaposi's  "  dermatitis  papil- 
laris capillitii." 

The  disease  may  show  itself  either  as  a  sycotic  affec- 
tion of  the  beard,  pubic  and  axillary  hairs,  passing 
over  at  times  to  the  scalp;  or  as  a  bald  area  upon  the 
scalp,  which,  upon  more  careful  examination,  will  be 
found  to  be  due  to  a  follicular  and  perifollicular  in- 
flammation of  the  hair-follicles. 

Folliculitis  decalvans  of  the  bearded  portion  of  the 
face  has  its  seat  of  predilection  upon  the  cheeks,  from 
whence  it  may  invade  the  temporal  region  of  the 
scalp.  It  begins  as  a  redness  of  the  skin,  which  is  soon 
followed  by  the  appearance  of  little  vesico  pustules 
at  the  mouths  of  the  hair  folHcles,  foi*ming  isolated 
islets  of  disease.  The  patches  soon  become  crusted 
and  appear  eczematous.  When  the  acute  process 
subsides  the  pustulation  ceases,  and  the  surface  of 
the  patches  becomes  red  and  scaly.  It  will  then  be 
noted  that  the  skin  is  cicatricial  and  the  hair  is  perma- 
nently destroyed.  There  may  be  but  one  patch  or  a 
number  of  them.  The  patches  may  be  symmetrical 
or  non- symmetrical.  They  tend  to  spread  slowly, 
serpiginously,  and  peripherally.  The  disease  is  ex- 
ceedingly chronic  in  its  course,  and  after  it  has  lasted 
a  number  of  years,  unless  it  has  been  of  very  limited 
extent,  the  bearded  portion  of  the  face,  and  perhaps 
the  temporal  regions  of  the  scalp,  wiU  be  found  sown 
over  with  cicatricial  spots  which  may  be  depressed, 
bridled,  or  keloidal 


FOLLICULITIS  DECALVANS.  199 

Folliculitis  decalvaiis  of  the  scalp  alone  simulates 
alopecia  areata  so  closely  as  often  to  be  mistaken  for 
that  disease.  Usually  the  first  thing  noted  is  the 
appearance  of  one  or  more  bald  spots,  and,  attention 
being  thus  attracted  to  the  scalp,  further  search  will 
reveal  evidences  of  folliculitis.  It  assumes  one  of  two 
forms:  1.  The  alojjecle  innomineeot  Besniev,  in  which 
we  find  on  the  scalp  irregular,  ill-defined  bald  patches 
bounded  by  bouquets  of  sound  hairs,  or  by  tufts  of 
hair  which  has  partially  fallen  out,  or  by  neighboring 
bald  patches.  The  scalp  appears  cicatricial,  thinned, 
slightly  depressed,  smooth  or  stippled  over  with  the 
follicular  mouth-openings,  and  with  or  without  pig- 
mentation. There  may  be  no  evidences  of  dermatitis 
or  traces  of  it  about  the  follicular  orifices.  Often  there 
is  a  slight,  diffused,  ill-defined  redness  with  furfura- 
ceous  desquamation ;  or  some  very  small  and  super- 
ficial pustules  occupying  the  inf  undibula  of  the  hair, 
which  in  a  short  time  are  transformed  into  depressions 
in  the  epidermis,  out  of  which  the  hair  deprived  of  its 
sheaths  falls  or  is  readily  plucked.  As  soon  as  the  hair 
falls  the  inflammation  subsides,  but  the  hair  has  been 
permanently  destroyed.  The  disease  spreads  in  a  very 
erratic  manner,  and  there  frequently  are  many  isolated 
spots  scattered  over  the  scalp. 

2.  This  is  the  folliciilite  epilante  of  Quinquaud. 
While  usually  affecting  the  scalp,  it  may  affect  the 
beard,  pubes,  and  axillcB.  It  resembles  the  first  variety 
in  producing  bald,  smooth,  irregular- shaped  cicatricial 
patches,  but  is  preceded  or  attended  by  a  more  marked 
folliculitis.  The  patches  are  disseminated;  about  the 
size  of  a  silver  quarter  of  a  dollar  or  a  franc  piece;  pale, 
with  a  few  red  points  in  them,  while  about  their  peri- 
pheries and  in  the  hair  of  neighboring  parts  are  various 
evidences  of  folliculitis,  such  as  purulent  points,  punc- 
tiform  miliary  abscesses,  with  hair  in  their  centres. 
When  these  hairs  fall  or  are  plucked  they  leave  a  redj 


200  DISEASES   OF   THE   HAIR   AND   SCALP. 

scarcely  moist  point.  Instead  of  pustules  there  may 
beonlypunctiform  redness,  with  or  vdthout  secondary 
desquamation,  or  red  follicular  papules.  The  succes- 
sive loss  of  a  number  of  hairs  produces  bald  patches 
of  large  size,  which  are  separated  from  each  other  by 
tufts  of  sound  hair.  There  is  never  any  appearance 
simulating  that  of  eczema. 

Etiology  axd  Pathology. — We  do  not  know  any- 
thing positive  about  the  cause  of  the  disease.  Quix- 
QUAUD  describes  a  micrococcus  as  the  cause  of  his 
folliculite  epilante,  which  occurs  as  a  monococcus, 
diplococcus,  and  in  series  of  four  in  the  follicles,  the 
blood,  and  in  the  inflamed  skin.  The  fluid  from  the 
cultivation,  when  rubbed  into  animals  and  man,  pro- 
duced a  disease  apparently  identical  with  the  parent 
disease.  In  all  forms  of  folliculitis  decalvans  there  is 
atrophy  of  the  hair-follicles  and  sebaceous  glands.  It 
has  been  surmised  that  some  of  the  cases  are  due  to 
syphilis. 

Diagnosis.  —  Folliculitis  decalvans  affecting  the 
bearded  portion  of  the  face  differs  from  sycosis  chiefly 
in  causing  cicatricial  destruction  of  the  skin  and  per- 
manent loss  of  hair.  Moreover,  its  pustules  are 
more  superficial  and  its  surface  is  never  so  crusted. 
It  occurs  in  patches,  and  not  so  disseminated  through 
the  hair,  and  affects  primarily  the  skin  between  the 
hairs  rather  than  the  hair-follicles  themselves.  Fol- 
liculitis decalvans  affecting  the  scalp  produces  bald 
spots  that  are  to  be  distinguished  from  those  of  alo- 
pecia areata  by  the  presence  of  inflammatory  symp- 
toms. Without  a  well-marked  history  of  the  occurrence 
of  favic  crusts  it  would  be  impossible  to  distinguish 
alopecia  from  old  f avus  from  an  alopecia  of  this  disease 
in  quiescence. 

Treatment  thus  far  has  been  inadequate  to  the  cure 
of  the  disease.  The  scalp  should  be  kept  clean  and 
some  mild  antiseptic  lotion  or  ointment  used. 


FOLLICULITIS  DECALVANS.  201 

The  Prognosis  is  bad.  The  course  of  the  disease  is 
slow,  and  permanent  baldness  follows.  After  a  time 
the  disease  may  reach  a  quiescent  stage. 


PART  III. 

PARASITIC  DISEASES  OF  THE  HAIR. 

Trichophytosis. — Favus.  — Pediculosis. —Beigel's 
Disease. — Trichomycosis  Nodosa. 


CHAPTEE    XII. 

TRICHOPHYTOSIS   CAPITIS. 

Synonyms. — Herpes  tonsurans;  Herpes  circinatus; 
Herpes  squamosus  (Cazenave);  Tinea  tonsurans; 
Tinea  tondens  (Malion);  Trichonosis  furfuracea  (De- 
vergie);  Porrigo  furfurans  (Devergie);  Porrigo  tonsoria 
(Alibert);  Trichosis  tonsurans  (Wilson);  Trichosis 
pityriasica  seu  furfuracea  (Wilson) ;  Trichoniykosis 
(Gruby);  Dermatomykosis  trichophytina;  Phytoalope- 
cia  seu  Trichomyces  tonsurans  (Malmsten);  Ehizo- 
phyto-alopecia  (Gruby);  Dermatomykosis  tonsurans 
(Kobner);  Squarus  tondens  (Mahon);  French,  Herpes 
tonsurante,  Teigne  tondante  (Mahon);  Teigne  tonsu- 
rante,  Teigne  annulaire  (Payer) ;  Teigne  herpetique  f ur^ 
furacee  (Gibert);  Trichophytie  tonsurante  (Hardy); 
Trichophytie  (Gruby);  Porrigine  tonsurantie  (Alibert); 
Dartre  furfuracee  arrondie  (Alibert);  L'herpes  circine 
parasitaire;  German,  Scherende  Flechte;  English, 
Eingworm  of  the  scalp;  Slew.  Eingskurv. 

Definition.— A  contagious  parasitic  disease  of  the 
hairy  scalp,  due  to  its  invasion  by  the  Trichophyton 
fungus;  and  characterized  by  the  formation  of  partially 
bald,  scaly,  more  or  less  circular  patches,  in  which 
''stumps"  of  broken- off  hair  will  be  found.  It  is  a 
disease  peculiar  to  children  and  runs  a  chronic  course. 

Symptoms. — Eingworm  of  the  hairy  scalp  begins,  like 
ringworm  of  the  body,  by  the  formation  of  a  small, 
round  erythematous  spot  upon  which  ephemeral  vesi- 
cles and  pustules  soon  form,  which  rapidly  go  on  to 
desquamation.  Or  the  spot  may  become  covered  with 
furfuraceous  scales  without  the  appearance  of  vesicles 


son 


DISEASES  OF  THE   HAIR   AND  SCALP. 


or  pustules.  This  stage  is  so  rapid  in  its  course,  and 
gives  SO  little  ainioyance  to  the  patient,  that  it  is  sel- 
dom brought  to  the  notice  of  the  physician.  The  patch 
spreads,  the  hairs  become  early  affected,  and  then  we 
have  the  typical  patch  of  the  disease  before  us.  This 
is  circular  in  shape;  denuded  of  hair,  though  not  com- 
pletely l)ald;  covered  with  a  greater  or  lesser  amount  of 
scales;  and  more  or  less  raised  above  the  surface  of 


Ringworm. 

the  scalp.  There  may  be  only  one  patch  upon  the 
head,  or  there  may  be  a  number  of  them.  The  size  of 
the  individual  patch  may  be  quite  small  or  it  may  be 
as  large  as  a  silver  dollar.  If  several  patches  occur 
close  to  each  other,  they  may  coalesce  and  form  a  huge 
patch,  which  may  involve  the  whole  top  of  the  head. 
The  color  of  the  patch  varies  somewhat;  it  may  be 
reddish,  gray,  slate,  greenish,  bluish  or  even  blackish. 
The  color  depends  upon  the  amount  of  scaling  present, 


TRICHOPHYTOSIS    CAPITIS.  207 

upon  the  complexion  of  the  individual,  upon  the  ex- 
tent to  which  the  inflammatory  process  has  gone,  and 
upon  the  admixture  of  dirt  or  foreign  matter.  If  the 
inflammation  is  but  shght,  and  the  complexion  is 
medimii,  the  patch  will  be  grayish  or  reddish.  In 
dark-skinned  subjects  the  color  is  apt  to  be  slate.  If 
in  a  strumous  subject,  and  pustulation  has  taken  place, 
we  wiU  meet  with  greenish  or  blackish  patches.  A. 
R.  Robinson  (33)  draws  attention  to  the  fact  that  some- 
times the  central  part  of  a  patch  may  be  gray  or  slate 
color,  and  the  periphery  yellowish  or  blackish  brown 
from  the  drying  up  of  the  vesicles  at  the  margin. 
Probably  '^slaty-gray"  wifl  best  describe  the  color  of 
the  majority  of  the  patches. 

The  amount  of  scaling  is  rarely  excessive,  and, 
though  at  times  abundant,  never  reaches  to  the  for- 
mation of  thick  mortar-like  crusts  such  as  we  meet  with 
in  favus.  In  a  case  complicated  with  eczema,  arising 
either  spontaneously  or  from  over  treatment,  thick  pur- 
ulent crusts  may  form,  but,  of  course,  quite  independ- 
ently of  the  ringworm.  Upon  the  removal  of  the  scales, 
the  exposed  scalp  will  be  found  reddened,  swollen, 
and,  it  may  be,  oedematous  and  tender.  In  chronic 
cases  the  scalp  will  be  merely  reddened  and  scaly,  and 
sometimes  of  goose-flesh  appearance. 

The  condition  of  the  hairs  is  characteristic.  They 
are  affected  very  early  in  the  course  of  the  disease,  be- 
coming dry,  lustreless,  opaque,  brittle,  twisted,  and 
readily  breaking  off  upon  the  slightest  traction,  or  of 
their  own  accord.  They  lose  their  elasticity,  as  shown 
by  taking  a  hair  and  pressing  it  with  the  nail,  when  it 
will  readily  bend  at  an  angle  which  it  will  retain.  If 
a  healthy  hair  is  subjected  to  the  same  treatment  it 
will  soon  regain  its  usual  form.  Another  proof  of  the 
loss  of  elasticity,  is  that  when  the  hair  is  combed  the 
wrong  way  upon  the  head,  while  the  healthy  haiis  will 


20S  DISEASES   OF  THE   HAIR  AXD  SCALP. 

immediately  fall  iiito  their  former  position,  the  affected 
ones  will  stand  up  for  a  moment,  and  then  slowly  fall. 
The  hairs  breaking  off  leave  their  roots  and  a  small 
portion  of  their  shafts,  it  may  be  only  one  or  two  hnes 
in  length,  in  the  seal}).  These  are  known  as  '  'stumps, ' ' 
and  are  pathognomonic  of  the  disease.  A  stump,  then, 
is  the  broken-off  shaft  and  root  of  a  ringworm  hair,  a 
few  lines  in  length,  with  a  ragged,  nibbled-off -looking 
end,  which  is  spht  and  frayed  out,  and  laden  with 
spores.  It  may  present  itself  as  only  a  minute  dark- 
colored  dot  on  the  scalp.  They  are  met  with  in  this 
disease  alone,  and  must  not  be  confounded  with  the 
ends  of  cut  or  accidentally  broken-off  healthy  hairs, 
which  are  not  spht  or  ragged,  and  do  not  contain  spores. 
The  amount  of  hair  present  in  a  patch  of  ringworm 
varies.  Sometimes  there  will  be  quite  a  number  of 
long  though  diseased  hairs;  sometimes  there  will  be 
only  stumps;  and  sometimes  both  are  present,  the 
stumps  being  superabundant.  In  a  typical  patch  there 
will  be  mostly  stumps,  which  give  to  it  the  appearance 
of  having  had  the  hair  cut  off  clumsily  with  a  dull 
pair  of  scissors.  In  some  cases,  as  the  result  of  treat- 
ment, or  when  the  disease  has  taken  an  exceptional 
course,  the  hairs  will  entu^ely  fall  out,  and  thus  there 
will  be  formed  a  completely  bald  spot. 

Ringworm  affects  by  preference  the  vertex  and  the 
parietal  regions,  though  it  may  occm*  anywhere  upon 
the  head,  and  at  times  may  pass  over  upon  the  skin  of 
the  face  or  neck.  The  only  subjective  symptom  w^hich 
it  presents  is  itching,  which  is  often  the  first  thing 
noticed,  and  leads  to  investigation  of  the  scalp.  It  is 
usually  slight.  The  disease,  though  chronic  in  its 
course,  and  obstinate  to  treatment,  is  yet  self-hmited, 
and  does  not  of  itself  cause  baldness. 

Besides  this  typical  form  of  trichophytosis  capitis, 
the  one  which  we   meet  ^\ith  in    the  vast   majority 


TRICHOPHYTOSIS    CAPITIS.  209 

of  cases,  there  are  several  other  forms  or  varieties. 
These  are  pustular  ringworm,  disseminated  ringworm, 
and  kerion.  The  last  differs  very  much  from  the  other 
varieties,  and  is  not  always  due  to  the  trichophyton 
fungus;  therefore  it  will  be  reserved  for  special  treat- 
ment. 

The  pushilar  form  of  ringworm  occurs  chiefly  in  ill- 
nourished  or  scrofulous  children.  Instead  of  a  scurfy 
place  forming,  we  have  pustules  produced,  and  green- 
ish crusts.  Sometimes  this  form  may  be  caused  by 
treatment,  too  strong  remedies  being  used,  or  remedies 
being  improperly  applied,  and  it  is  especially  prone  to 
occur  in  eczematous  subjects.  It  is  indeed  an  impeti- 
ginous eczema,  complicating  a  ringworm  of  the  scalp, 
and  may  involve  a  large  portion  of  the  scalp.  The  pro- 
cess is  superficial,  and  if  the  crusts  are  removed, under 
them  will  be  found  the  characteristic  stumps.  Alder 
Smith  (79)  regards  this  form  as  especially  liable  to  spread 
amongst  schools.  It  is  not  the  same  disease  as  is  the 
deep  inflammatory  process  called  kerion.  Sometimes 
we  meet  with  a  chronic  pustular  ringworm,  which 
presents  pustules  pierced  by  hairs. 

Disseminated  ringivorm  is  that  form  in  which,  in- 
stead of  a  single  patch  or  a  number  of  patches  occur- 
ring on  the  scalp,  the  disease  involves  more  or  less  of 
the  whole  scalp,  not  in  the  form  of  patches,  but  diffused 
throughout  the  hair.  The  hair  may  seem  to  be  growing 
weU,  but  when  the  scalp  is  inspected,  we  will  find  it 
scurfy,  as  in  eczema  or  pityriasis;  most  of  the  hair  will 
be  of  normal  length  and  appearance,  but  here  and  there 
wiU  be  found  a  number  of  stumps,  either  isolated  or  in 
groups,  or  there  may  be  only  black  dots  on  the  surface, 
the  roots  of  broken-off  stumps.  The  long  hair  may 
be  firmly  fixed  or  may  come  out  easily.  This  form  is 
seen  most  frequently  in  chronic  cases ;  and  is  often  over- 
looked.    It  will  sometimes  last  in  this  sluggish  condi- 


210  DISEASES   OF   THE   HAIR  AXD   SCALP. 

tion  for  years  after  the  well-defined  patches  have  dis- 
appeared, and  tlie  case  is  considered  by  the  physician 
and  the  friends  as  cured. 

Chronic  squamous  ringworm  is  that  form  in  which 
we  meet  ^^^th  a  patch  or  patches  of  the  disease  which  do 
'  not  spread,  and  which  are  pai-tiaUy  covered  with  appar- 
ently healthy  hair.  The  patch  is  stiU  scurfy,  and  the 
hair  may  look  a  little  dry,  as  it  is  commonly  met  Tvath 
in  seborrhoea,  but  that  may  be  all  wiiich  arouses  our 
suspicions.  Upon  careful  examination  stumps  will  be 
found  close  to  the  scalp,  hidden  by  the  long  hair. 

The  incubation  period  of  ringworm  has  been  shown 
by  experiment  to  be  about  three  days.  Its  rate  of 
growth  is  rapid,  a  spot  as  large  as  a  ten- cent  piece  may 
develop  in  forty-eight  houi^s,  and  attain  the  size  of  a 
fifty-cent  piece  in  twenty-four  hours  more.  When  it 
has  reached  the  size  of  a  silver  dollar,  it,  in  most  cases, 
ceases  to  enlarge.  The  hfe  of  the  fungus  is  also  lim- 
ited. Though  the  disease  may  have  lasted  many  years 
in  a  cliild,  it  tends  to  get  well  as  the  child  reaches  the 
age  of  puberty. 

The  scalp  is  not  the  only  hairy  region  affected  by 
the  trichoph\i:on  fungus.  The  beard  is  its  frequent 
habitat.  It  may  also  occur  upon  the  pubes  and  in  the 
axiUa,  and  give  rise  to  appearances  somewhat  similar 
to  those  met  ^vith  in  ringworm  of  the  beard. 

Etiology. — Trichophytosis  capitis  is  due  to  a  single 
cause,  the  implantation  and  growth  of  the  trichophy- 
ton fungus.  This  view  is  one  now  accepted  by  aU 
dermatologists,  though  up  to  quite  recent  years,  there 
were  some  eminent  ones  who  beheved  it  to  be  a  disease 
of  nutritive  debihty .  Thus  Wilson  (33)  taught  ' '  that  it 
was  essentially  an  aiTest  of  development  of  the  hair- 
cells  and  the  cells  of  the  rete  mucosum.  That  the  cells 
retained  their  primitive  molecular  character,  and  the 
gi-anules  taking  on  a  proliferous  growth  are  converted 


TRICHOPHYTOSIS    CAPITIS.  211 

into  a  tissue  closely  resembling  a  mucedinous  vegeta- 
tion." 

The  fungus  gains  lodgment  in  the  upper  layers 
of  the  epidermis,  after  the  most  superficial  layers 
are  removed  in  some  v^ay,  and  from  its  point  of 
entrance,  spreads.  Liveing  (452)  thinks  that  the  fun- 
gus is  not  the  essence  of  the  disease,  but  plays  a  sec- 
ondary, though  important  part,  in  its  development. 
His  reasons  are  the  following:  First. — The  food  of 
this  kind  of  vegetable  parasite  is  dead  or  dying  struc- 
tures. Secondly. — The  development  of  the  fungus  is 
not  always  in  proportion  to  the  changes  present  in  the 
skin  and  hair,  showing  that  other  causes  are  at  w^ork. 
Thirdly. — In  many  cases  the  comparatively  healthy 
hair  of  the  whole  scalp  loses  its  lustre  and  becomes 
harsh,  dry,  brittle  and  more  opaque  than  in  health, 
without  the  growth  of  the  fungus  beyond  the  ring- 
worm patches,  and  this  condition  may  persist  for 
months  after  the  parasitic  growth  has  disappeared. 
Fourthly. — If  the  fungus  were  the  essence  of  the  dis- 
ease we  should  expect  the  malady  to  be  less  capricious 
in  its  nature. 

The  disease  is  very  contagious,  much  more  so  than 
is  favus.  It  is  nearly  always  endemic  and  sometimes 
epidemic.  When  it  gains  entrance  into  a  school  or 
children's  hospital  or  asylum,  it  spreads  with  great 
rapidity,  and  such  institutions  are  the  most  important 
agents  in  keeping  it  alive.  Bergeron  (45)  has  shown 
that  in  France  it  is  more  common  in  cities  than  in  the 
country.  It  attacks  children  almost  exclusively.  It 
is  rare  to  meet  with  it  after  puberty,  excessively  rare 
to  see  it  on  the  head  of  an  adult,  and  very  infrequent 
in  infants.  This  shows  that  it  requires,  like  other 
parasites,  some  peculiar  condition  of  the  soil  for  its 
growth,  though  what  that  condition  may  be  is  not  yet 
determined.    It  attacks  all  classes  of  children,  the  rich 


212  DISEASES   OF   THE   HAIR  AND   SCALP. 

and  the  poor,  the  clean  and  the  uncared  for.  It  occurs 
often  amongst  strumous  children,  and  those  who  are 
badly  nomished;  but  as  these  cliildi-en  are  found  most 
frequently  in  those  classes  which  hve  under  other  con- 
ditions favorable  to  infection,  it  is  difficult  to  determine 
the  exact  predisposing  force  of  the  diathesis.  When 
the  disease  gains  entrance  into  asylums  and  schools  it 
shows  no  disposition  to  spare  the  healthy  and  robust 
children.  Tilbury  Fox  (12)  taught  that  cliildren  of 
lymphatic  temperament  w^ere  j^rone  to  the  disease. 

The  means  of  infection  are  mediate  and  intermedi- 
ate. Thus^  it  is  readily  conveyed  directly  from  the 
body  or  head  of  one  infected  pei-son  to  the  head  of 
another,  or  from  the  body  of  a  cluld  to  its  own  head, 
ringworms  sometimes  passing  over  from  the  non-hairy 
to  the  hairy  parts.  It  may  also  be  communicated 
from  animals,  the  disease  being  common  in  cats  and 
dogs,  and  it  is  met  with  in  cows,  horses,  rabbits,  squir- 
rels and  other  domestic  or  pet  animals.  In  epidemics 
of  ringworm  in  children's  hospitals,  the  au'  of  the 
room  has  been  found  loaded  T\ith  floating  spores.  The 
most  common  means  of  mediate  contagion  are  hats, 
caps,  bi-ushes,  and  combs. 

Pathology. — The  disease  is  caused  by  the  vegeta- 
ble fungus  called  tricophyton  tonsurans  or  acliorion 
Lebertii.  This  consists  of  myceha  and  conidia,  which 
bear  a  close  resemblance  to  those  of  the  peniciUium 
glaucum.  It  is,  without  doubt,  a  distinct  species  of 
vegetable  growi;h,  resembhng  (though  not  the  same  as) 
the  acliorion  Schoenleinii,  as  inoculations  made  with 
pure  cultures  produce  ringworm  alone.  On  the  other 
hand  inoculations  with  pui'e  cultui'es  of  the  achorion 
Schoenleinii  give  rise  to  favus  alone.     It  is  aerobic. 

In  the  hair  the  conidia  are  far  more  numerous  than 
the  myceha,  and  sometimes  are  present  in  such  num- 


TRICHOPHYTOSIS  CAPITIS. 


213 


bers  as  apparently  to  burst  the  hair, 
often  found  arranged  in 
rows  parallel  with  the 
long  axis  of  the  hair. 
Sometimes  they  are  scat- 
tered irregularly  through 
the  hair;  usually  they 
are  so  numerous  about 
the  bulb  and  root  as  to 
appeared  crammed  to- 
gether. They  are  round, 
highly  refractive  bodies, 
of  a  grayish  or  pale  green 
color,  and  a  diameter  of 
from  .0021  mm.  to  .0035 
mm. 

The  mycelia  are  often 
absent  from  specimens 
examined.  When  pre- 
sent they  run  through  the 
hair  in  its  long  diameter, 
and  are  long,  jointed  and 
wavy.  Their  diameter 
varies  from  .0018  mm.  to 
.0026  mm. 

Bacteriologists,  by  their 
more  advanced  methods 
of  staining  and  cultiva- 
tion, are  striving  to  ad- 
vance our  knowledge  of 
the  micro-organisms  of 
the  skin.  Furthmann 
and  Neebe  (329  ap.)  be- 
lieve that  they  have  found 
no  less  than  four  different 
worm,    resembling    each   other    very 


The  conidia  are 


fi|iff|t 

Trichophyton  (Smith). 

finigi  as  causes  of 
closely, 


rmg- 
and 


214  DISEASES  OF  THE  HAIR  AND  SCALP. 

distingiiislied  one  from  the  other  mostly  by  their 
cultures.  It  is  probable  that  the  fungus  of  ringworm, 
like  other  fungi,  varies  in  form  and  manner  of  growth 
according  to  the  physical  and  chemical  properties  of 
the  soil  in  which  it  grows,  and  that  after  all  there  is 
but  one  micro-organism  in  ringworm.  Quincke  (:^48 
ap.)  has  found  that  the  fungus  of  ringworm  has  many 
points  of  resemblance  to  his  ^-fungus  of  favus,  but 
differed  also  in  many  respects.  It  grows  slower  on 
gelatin,  with  greater  tendency  to  grow  downward;  and 
more  rapidly  on  agar-agar.  Under  the  microscope  its 
mycelia  were  simply  rounded  and  not  tapering,  and 
were  straighter.     It  would  not  grow  on  potato. 

In  1S02  Sabouraud  (354  ap.)  pubhshed  what  seems 
to  me  to  be  one  of  the  most  important  contributions 
to  our  knowledge  of  ringworm.  He  beheves  that  the 
fungus  belongs  to  the  botanical  species  of  Botrytis,  of 
^\'hich  there  are  probably  a  number  of  distinct  species 
capable  of  causing  trichophytosis  in  different  animals. 
In  the  human  there  are  two  principal  varieties,  viz.: 
1.  This  has  small  spores  and  is  found  only  on  the 
scalp.  It  is  the  constant  cause  of  the  disease  on  the 
infant's  scalp  and  of  all  the  obstinate  cases.  Under 
the  microscoj^e  it  has  a  spore  of  3  /<  in  diameter,  with 
no  mycelia.  The  hairs  are  full  of  the  spores,  and  they 
escape  from  it  to  form  a  sheath  about  it.  2.  The 
other  species  has  large  spores.  It  may  cause  tricho- 
phytosis capitis,  and  is  found  in  thirty  five  per  cent. 
of  the  cases,  and  these  are  easy  to  cure.  It  is  the 
common  cause  of  trichophytosis  barbae,  and,  with 
another  special  large-spore  species,  is  the  cause  of 
trichophytosis  corporis,  specially  when  that  follows 
upon  the  disease  in  the  beard.  It  has  a  spore  of  7-8  >u 
diameter,  T\ith  visible  myceha. 

A  case  with  one  species  of  spores  produces  by  con- 
tagion a  case  with  the  same  species,  and  no  case  pre- 


TRICHOPHYTOSIS   CAPITIS.  215 

sents  both  varieties  at  the  same  time.  The  patches 
caused  by  the  small  spores  are  round  or  obloiig,  and 
usually  not  more  than  5  cm.  in  diameter.  At  the  be- 
ginning they  are  raised  and  the  scalp  feels  thickened 
and  infiltrated.  The  affected  hairs  are  usually  fine, 
and  they  are  almost  constantly  broken  off  at  more  than 
3  mm.  from  the  mouth  of  the  follicle.  The  jjatches 
caused  by  the  large  spores  are  more  often  large  than 
small,  irregular  in  shape,  Avitli  tufts  of  healthy  hair 
that  encroach  on  the  circumference  of  the  patch.  It 
looks  almost  completely  bald  because  the  diseased 
hairs  are  cut  off  very  short.  The  hairs  are  often  of 
large  size  and  appear  as  black  points  at  the  follicular 
orifices.  Besides  these  common  species  Sabouraud 
has  found  two  more  rare  types.  One  of  these  has 
large  spores  and  occurs  in  trichophytosis  corporis.  It 
differs  from  the  other  large  spore  species  in  its  more 
vigorous  and  rapid  growth  with  a  fluffy  centre  in 
cultures.  The  other  species  presents  large  and  un- 
equally-sized spores.  He  also  found  in  one  cultivation 
bliick,  and  in  another  rose-colored,  spores  that  are 
th  jught  to  be  forms  found  only  in  animals. 

He  found  that  he  would  have  to  make  many  at- 
tempts before  succeeding  in  inoculating  some  subjects, 
and  that  the  patient  must  have  an  alkaline  reaction 
to  his  sweat  before  success  can  be  obtained. 

The  hair  in  ringworm  of  the  scalp  is  early  affected, 
the  first  point  attacked  being,  according  to  Taylor  (4Sn> 
that  portion  of  the  shaft  immediately  on  a  level  with 
the  surface  of  the  skin,  from  which  point  it  spreads 
up  and  down.  The  cortical  substance  in  its  peripheral 
part  is  the  most  frequent  and  earliest  seat  of  the  fun- 
gus; but  the  whole  hair  is  frequently  involved.  Ac- 
cording to  most  observers  the  bulb  is  invaded  to  only 
a  slight  extent  and  the  papilla  and  root-sheaths  are 
spared.     A.  R.  Robinson  (33)  has  met  with  the  spores 


216  DISEASES   OF   THE   HAIR   AND   SCALP. 

and  mycelia  in  the  root-sheath  and  even  in  the  perifol- 
liculai'  tissue.  However,  as  a  inile  it  may  be  stated 
that  the  part  of  the  hair  most  infected  is  above  the 
neck  of  the  folhcle.  It  grows  up  to  a  long  distance  in 
the  shaft,  but  seldom  if  ever  to  the  point  of  the  hair. 
When  present  in  the  hair,  in  small  amount,  the  hair 
preserves  its  cuticle  entire,  and  looks  scarcely  altered. 
When  present  to  such  an  extent  as  to  cause  fracture 
of  the  hair  and  the  formation  of  stumps,  the  cuticle 
will  be  broken,  the  whole  stump  wiU  be  disorganized, 
and  its  end  frayed  out.  Often  the  hair  under  the 
microscope  seems  as  if  it  had  burst  at  many  points 
and  allowed  the  spores  to  escape.  In  such  a  case  the 
spores  will  be  found  lying  along  the  outside  of  the  hair- 
shaft,  and  grouped  and  scattered  about  the  fractured 
portion.  In  some  cases  some  hairs  in  a  patch  will  es- 
cape for  some  time,  but  eventually  all  will  become 
involved. 

The  amount  of  irritation  caused  by  the  fungus  wiU 
vary  with  the  amount  of  the  fungus  and  its  seat. 
W^hen  only  a  few  spores  are  present,  and  these  are 
su])erficially  seated,  the  scalp  will  be  only  shghtly  red- 
dened and  scaly,  or  there  may  be  some  vesiculation. 
When  the  spores  are  present  in  greater  number,  and 
have  penetrated  into  the  hair-foUicles,  they  will  cause 
more  redness  of  the  scalp,  a  greater  or  less  amount  of 
perifollicular  inflammation,  and  tumefaction  of  the 
scalp.  The  extreme  degree  of  irritation  is  that  met 
with  in  kerion,  as  we  shall  learn  in  another  place. 
Behrend  (3)  well  points  out  the  difference  between  the 
growth  of  the  fungus  in  ringworm  and  favus,  when 
he  says:  ^'  The  achorion  remains  for  a  long  time  con- 
fined to  the  superficial  layers  of  the  hair,  growing 
quite  high  up  in  the  shaft,  while  the  trichophyton 
involves  in  a  few  days  the  whole  thickness  of  the  hair 
and  makes  it  brittle,  so  that  it  breaks  upon  the  shght- 


TRICHOPHYTOSIS   CAPITIS.  217 

est  traction.  On  this  account  the  hairs  of  favus  pre- 
serve their  normal  hastre  and  consistence,  while  those 
of  ringworm  very  soon  lose  the  same." 

Diagnosis. — The  diagnosis  of  atypical  patch  presents 
no  difficulty,  as  there  is  no  other  disease  which  occurs 
in  the  form  of  round,  partially  bald,  scaly  patches, 
with  disorganized  hairs  and  "stumps"  growing  in 
them.  But  at  times  cases  do  occur  which  are  not  so 
easily  made  out.  Seborrhoea,  psoriasis,  favus.  lupus 
erythematosus,  and  eczema  occur  upon  the  scalp  in 
the  form  of  scaly  patches;  alopecia  areata  causes  cir- 
cular bald  patches;  and  the  other  forms  of  alopecia 
denude  the  scalp  of  hair.  From  these,  then,  under 
certain  conditions,  ringworm  of  the  scalp  must  be 
differentiated. 

1.  From  seborrJicea  sicca  capitis. — Seborrhoea  may 
appear  at  any  time  of  life.  Ringworm  is  almost  ex- 
clusively confined  to  childhood.  Seborrhoea  has  no 
history  of  contagion,  and  is  variable  in  its  course, 
getting  better  and  worse  of  itself.  In  ringworm  it  is 
generally  easy  to  trace  the  case  back  to  its  source  of 
contagion,  and  the  disease  once  started  is  progressive, 
showing  little  tendency  to  get  well  of  itself  until  pu- 
berty is  reached,  when  it  generally  disappears  com- 
pletely, never  to  return.  Seborrhoea  involves  the  scalp 
pretty  generally  and  uniformly;  if  it  form  patches 
they  are  irregular  and  not  sharply  defined.  Ringworm 
usually  occurs  in  one  or  more  isolated  sharply  defined 
patches,  affecting  by  preference  the  vertex.  The  scales 
of  seborrhoea  are  prone  to  heap  up  into  thick  masses, 
and  are  tenacious  and  greasy  to  the  feel.  In  ring- 
worm they  are  seldom  heaped  up,  are  readily  detached, 
and  are  not  so  greasy.  Seborrhoea  may  cause  bald- 
ness, this  condition  being  usually  preceded  by  a  progres- 
■sive  thinning  of  the  hair-calibre  over  a  series  of  years, 
and  affecting  the  top  of  the  head.     With  the  increase 


218  DISEASES   OF   THE   HAIR   AND   SCALP. 

of  the  baldness  there  will  be  a  decrease  of  the  sebor- 
rhoea,  and  the  baldness  \\ill  be  complete  and  permanent. 
In  seborrhoea  there  is  a  complete  absence  of  the 
tichoph}i:on  fimgiis,  and  ''stumps." 

2.  From  j^soriasis. — Psoriasis  occui^s  in  the  form  of 
thick,  crusted  patches  scattered  more  or  less  over  the 
whole  scalp,  and  tending  to  form  a  row  of  characteristic 
lesions  along  the  margin  of  the  hair  upon  the  forehead. 
Ringworm  is  more  apt  to  be  confined  to  the  vertex,  its 
patches  are  scaly,  and  if  it  encroaches  upon  the  non- 
hairy  paris,  it  vriM  form  a  characteristic  patch  of  ring- 
worm of  the  body.  Psoriasis  does  not  affect  the  hair; 
ringworm  causes  partial  alopecia  In  psoriasis  there 
will  be  a  history  of  relapses  in  many  cases;  this  is 
entirely  absent  in  ringworm.  In  psoriasis  there  is  no 
histoiy  of  contagion;  in  ringworm  there  is  such  a 
history  in  the  majority  of  cases.  Psoriasis  rarely  if 
ever  occurs  on  the  scalp  alone,  and  therefore  charac- 
teristic patches  of  the  disease  wiU  be  found  upon  the 
arms  or  elsewhere;  ringworm  is  quite  commonly  con- 
fined to  the  scalp. 

3.  From  favus. — Favus  is  an  impoi-ted  disease  in 
this  country  in  the  vast  majority  of  cases,  and  hence 
is  seen  mostly  in  foreigners;  ringworm  is  endemic 
and  often  epidemic.  Favus  presents  either  the  path- 
ognomonic cupped  cimsts,  or  else  thick  masses  of  mor- 
tar or  asbestos-hke,  grayish,  friable  crusts;  ringworm 
has  no  cupped  ciTists,  and  the  scaling  is  but  slight. 
Favus  causes  distinct,  irregular,  perfectly  smooth, 
atrophic-looking,  red,  bald  patches,  scattered  over  the 
whole  scalp;  ringworm  causes  only  partially  bald, 
shghtly  scaly,  circular,  grayish  patches,  confined  most 
often  to  the  vertex  or  side  of  the  head,  and  the  scalp 
is  not  atrophic.  In  favus  .the  hair  is  affected  second- 
arily, and  readily  pulls  out  ientire  with  its  root;  in 
ringworm  the  hair  is  early  affected,  and  when  pulled 


TRICHOPHYTOSIS  CAPITIS.  210 

on  it  breaks  easily  and  leaves  its  root  behind  in  the 
scalp,  forming  the  '^  stump."  Favus  is  a  very  chronic 
disease,  shows  little  tendency  to  get  well  of  itself,  and 
often  lasts  until  late  in  life;  ringworm  is  not  so  chronic, 
is  most  often  seen  in  children,  tends  to  get  well  of  it- 
self as  its  subject  reaches  puberty,  and  is  rarely  met 
with  in  adults.  Under  the  microscope  the  mycelia 
and  conidia  of  favus  scales  are  seen  to  be  slightly  larger 
than  those  of  ringworm.  Its  conidia  are  more  mani- 
fold in  shape,  being  ovoid,  often  elongated,  and  some- 
times dumb-bell  shaped,  while  the  conidia  of  ringworm 
are  uniformly  round.  In  favus  the  hairs  are  mostly 
invaded  by  mycelia  which  may  be  seen  as  long  fila- 
ments in  the  hair;  in  ringworm  the  conidia  are  found 
in  superabundance,  often  exclusively,  and  so  numerous 
at  times  as  to  burst  the  hair.  It  must,  however,  be 
said  that  it  is  very  difficult  for  any  but  the  most 
expert  microscopist  to  always  distinguish  between  the 
fungi  of  the  two  diseases,  as  they  at  times  resemble 
each  other  very  closely.  Cultivation  of  the  fungus  is 
the  only  sure  method  of  diagnosis. 

4.  From  lupus  erythematosus. — The  only  resemblance 
it  has  to  ringworm  is  the  formation  of  a  scaly  bald 
patch;  but  there  is  no  history  of  contagion,  the  course 
of  the  disease  is  slower,  the  hair  is  affected  secondarily, 
the  patch  has  a  cicatricial  depression  in  the  centre,  and 
is  of  irregular  outline.     There  is  no  fungus  to  be  found. 

5.  From  eczema. — Squamous  eczema  is  the  form 
which  is  most  apt  to  be  confounded  with  ringworm. 
At  times  a  pustular  eczema  may  complicate  a  case  of 
ringworm,  or  a  case  of  disseminated  ringworm  may 
simulate  a  pustular  eczema. 

Squajnous  eczema. — Squamous  eczema  has  no  his- 
tory of  contagion;  in  ringworm  the  history  of  contagion 
can  generally  be  made  out.  Squamous  eczema  attacks 
all  ages  from  infancy  to  old  age;  ringworm  is  usually 


220  DISEASES   OF   THE   HAIR  AND   SCALP. 

met  with  in  childhood  alone,  sparing  infants  and  not 
lasting  after  puberty  is  reached.  Squamous  eczema 
often  is  diffused  over  the  whole  scalp,  and  when  it 
does  occur  in  patches  they  are  not  sharply  defined; 
ringworm  occm's  in  more  or  less  circular,  sharply  de 
fined  patches.  Squamous  eczema  is  very  itchy  and  the 
scalp  shows  scratch-marks;  ringworm  is  but  slightly 
itchy  and  scratch-marks  are  not  commonly  found.  The 
scales  of  squamous  eczema  can  be  removed  in  plates 
though  they  are  thin;  the  scales  of  ringworm  are  more 
powdery  and  bulky.  The  hau*  in  squamous  eczema  is 
not  affected,  is  firmly  implanted  in  the  scalp,  and  when 
epilation  is  attempted,  it  is  painful;  in  ringworm  the  hair 
is  early  affected,  dry,  lustreless,  and  either  comes  out 
readily  and  painlessly  on  slight  traction,  or  breaks  off. 
In  squamous  eczema  there  are  no  "  stumps;  "  in  ring- 
worm they  are  always  present,  and  give  the  diagnosis, 
even  if  eczema  occurs  as  a  comphcation  of  the  ring- 
worm. 

PHsfulm^  eczema.  —  A  pustular  eczema  will  only 
need  to  be  differentiated  from  that  rare  form  of  dis- 
seminated and  pustular  ringworm.  Here  the  condi- 
tion is  one  of  ringworm  plus  eczema.  The  diagnosis 
is  made  by  the  presence  or  absence  of  the  characteristic 
hairs  and  stumps  of  ringworm.  In  doubtful  cases  the 
microscope  will  decide. 

G.  Ft'om  alopecia  areata. — In  t}^ical  examples  of 
this  disease  there  should  be  no  mistake  in  diagnosis. 
The  perfectly  smooth,  non-scaly,  non-pruriginous,  per- 
fectly bald  patch  of  alopecia  areata  is  in  strong  contrast 
to  the  rough,  scaly,  more  or  less  itchy,  partially  bald 
patch  of  ringworm  in  which  are  stumps  and  diseased 
hairs.  Alopecia  areata  comes  on  suddenly,  often  A\ath 
antecedent  symptoms  of  headache  and  pain  in  the  scalp, 
and  the  patch  is  formed  at  once.  Eingworm  comes  on 
with  comparative  slo%\Tiess,  and  Tvithout  antecedent 


TRICHOPHYTOSIS   CAPITIS.  ^21 

symptoms.  Alopecia  areata  occm^s  at  a  later  period  of 
life  than  does  ringworm,  as  a  rule;  and  if  a  circular, 
circumscribed  bald  spot  occur  in  an  adult,  it  is  far  more 
likely  to  be  one  of  alopecia  areata  than  of  ringworm. 
Sometimes  a  patch  of  alopecia  areata  will  present  a 
number  of  black  dots,  the  unf  alien  roots  of  hair,  which 
may  bear  some  resemblance  to  the  stumps  of  ringworm, 
but  if  they  are  examined  under  the  microscope,  the 
root  will  appear  shrunken  and  atrophied,  and  there 
will  be  an  entire  absence  of  the  spores  and  mycelia  of 
ringworm.  Sometimes  a  patch  of  ringworm  will  be 
perfectly  smooth  and  without  stumps.  This  is  usually 
the  result  of  treatment.  Stumps  will  be  found  else- 
where on  the  scalp,  or  diseased  hairs,  if  the  disease  be 
ringworm,  and  the  fungus  will  be  fomid  in  the  scales 
from  the  border  of  the  patch. 

7.  From  other  forms  of  alopecia. — The  history  and 
course  of  other  forms  of  baldness,  as  well  as  the  time  of 
their  appearance,  are  so  different  from  wdiat  ol)tains 
in  ringworm,  as  hardly  to  give  rise  to  any  difficulty. 

The  recognition  of  the  presence  of  the  fungus  in  the 
hair  by  the  aid  of  the  microscope  is  easy  after  a  Httle 
practice.  All  that  is  needed  is  a  microscope  with  a 
lense  magnifying  some  25()  diameters,  a  slide  and  cov- 
eiing  glass,  and  a  drop  of  hquor  potassae  with  or  with- 
out glycerine.  After  dropping  the  liq.  potass,  upon 
the  hair,  (a  stump  is  the  best  one  to  examine,)  and  put- 
ting on  the  covering  glass,  wait  a  few  minutes  before 
looking  at  the  specimen.  The  mycelia  will  be  recog- 
nized as  long,  branched,  jointed  threads  rumiing  up  the 
hair-shaft,  and  the  spores  will  be  seen  as  small,  round, 
refracting  bodies  in  rows  or  closely  packed  together. 
Care  must  be  exercised  not  to  mistake  air-bubbles  for 
spores.  Air-bubbles  are  recognized  by  their  change  of 
color  upon  changing  the  focus  of  the  microscope.  It 
is  also  possible  to  mistake  the  striated  condition  of  the 


222  DISEASES   OF   THE   HAIR  AXD   SCALP. 

hair  for  the  mycelia,  but  a  httle  care  and  practice  will 
prevent  this. 

Dyce  Duckworth  (421)  has  pointed  out  a  ready  means 
of  determining  the  presence  of  fungus  in  hair,  which 
is  by  laying  the  suspected  hair  in  chloroform,  and  al- 
lowing the  chloroform  to  evaporate.  If  fungus  is  pre- 
sent the  hair  will  become  white  or  primrose  yellow 
where  the  fungus  is.  But  this  reaction  is  not  pecu- 
liar to  ringworm,  as  it  is  also  found  in  favus  and 
pityriasis  versicolor. 

The  recognition  of  the  disseminated  form  of  ring- 
worm is  often  a  most  difficult  task,  but  it  is  most 
important  for  the  physician  to  recognize  it,  as  one  such 
unsuspected  case  may  be  the  cause  of  fresh  epidemics. 
To  examine  these  cases  the  child  should  be  placed  with 
its  face  to  the  light  and  its  back  to  the  physician 
Then  the  hair  is  to  be  turned  back  on  the  head  in  the 
opposite  direction  to  its  gi'OT\i:h.  By  carefully  watching 
the  scalp,  some  stumps  will  be  found  here  and  there; 
and  Tilbury  Fox  has  shoT\Ti  that,  if  there  are  any 
diseased  hairs  present,  they  will  stand  out  from  the 
head  after  the  normal  hairs  have  fallen  into  their 
places. 

Treatment. — That  nothing  is  easier  to  cure  than  a 
recent  case  of  ringworm  of  the  body  all  will  agree. 
That  a  chronic  case  of  ringworm  of  the  scalp  is  very 
difficult  to  cure  all  writers  and  observers  attest.  Our 
treatment  must  vary  with  the  stage  of  the  disease. 
External  applications  are  far  more  valuable  than  in- 
ternal medication;  and  indeed  the  former  may  be  relied 
on  in  the  vast  majority  of  cases  for  the  cure  of  the 
disease  without  recourse  to  the  latter. 

General  Treatment. — If  the  patient  is  evidently 
strumous  or  any  way  out  of  health,  of  course  he 
should  be  given  the  internal  treatment  best  -fitted 
to    his    case,    such    as    cod-liver    oil,    iron,    arsenic, 


TRICHOPHYTOSIS   CAPITIS.  ^23 

etc.  Attention  to  the  patient's  general  surround- 
ings is  in  most  cases  of  more  service  than  giving 
medicines.  An  infected  child  should  be  isolated  as 
much  as  possible,  and  by  all  means  kept  out  of  school. 
Isolation  can  and  ought  to  be  rigidly  practiced  in  all 
children's  asylums,  and  the  attending  physician  should 
see  to  it  that  the  infected  children  do  not  come  in 
contact  with  the  healthy  ones.  In  private  families 
isolation  cannot  be  so  readily  accomplished,  but  much 
may  be  done  to  prevent  the  disease  spreading  to  other 
children  in  the  family  by  having  the  infected  child 
sleep  by  itself;  by  providing  towels,  brush  and  comb 
for  its  special  use;  and  letting  it  wear  a  close-fitting 
linen  cap.  Other  children  should  not  wear  the  infected 
one's  clothing,  for  not  only  do  caps  carry  the  conta- 
gion, but  also  the  collars  of  jackets  and  coats.  The 
patient's  head  must  be  kept  saturated  \\ath  an  antipar- 
asitic oil,  lotion,  or  ointment  during  the  whole  course 
of  treatment,  to  kiU  the  loose  spores  and  prevent  them 
from  being  earned  to  other  heads.  For  this  purpose 
we  may  use  either  a  two  per  cent,  salicylated  oil,  that 
is  salicylic  acid  in  castor  oil;  a  saturated  solution  of 
boracic  acid;  a  two  to  five  per  cent,  carbolized  oil;  a 
solution  of  hyposulphite  of  soda,  two  drachms  to  the 
ounce;  or  an  ointment  of  sulphur,  one  drachm  to  the 
ounce;  or  one  of  the  ammoniate  of  mercury.  Of  course 
this  does  not  exhaust  the  list  of  useful  applications, 
but  the  ones  mentioned  are  probably  the  best.  My 
own  preference  is  for  the  salicylated  oil,  as  it  is  odor- 
less and  efficient. 

Local  Treatment. — In  the  local  treatment  of  the  dis- 
ease our  chief  reliance  is  upon  the  use  of  parasiticides, 
to  which  in  some  cases  epilation  must  be  added.  The 
remedies  that  we  caU  parasiticides,  such  as  mercury, 
chrysarobin,  pyrogallol,  and  the  like,  have  been  sup- 
posed by  some  observers  to  do  good,  not  by  any  speci- 


224  DISEASES   OF   THE   HAIR  AND   SCALP. 

fic  action,  but  by  tbe  production  of  inflammation  and 
scaling.  (We  know  that  the  fungus  cannot  live  in  the 
presence  of  pus,  and  for  that  reason  we  employ,  in 
very  chronic  cases,  croton  oil  to  produce  acute  pustu- 
lation.  Here  the  good  done  is  due  to  the  inflamma- 
tion produced  by  the  remedy.)  It  is  true  that  many 
of  them  do  have  this  action,  but  as  ring-^vorm  can  be 
cured  by  these  remedies,  without  the  production  of 
inflammation,  and  as  no  exfoliation  of  the  epidermis 
caused  by  them  could  account  for  the  cure  of  tricho- 
phytosis pilaris,  we  must  hold  that  they  do  act  by  vir- 
tue of  their  specific  action  upon  the  fungus. 

The  first  step  in  the  treatment  of  all  cases  is  to  have 
the  head  well  washed  with  soap  and  water,  and  all 
crusts  removed.  After  washing,  the  parasiticide  is  to 
be  applied  at  once,. miless  epilation  is  practised.  The 
frequency  with  which  shampooing  of  the  scalp  is  to 
be  repeated  will  vary  with  the  remedial  apphcation 
iised.  As  a  rule  it  may  be  stated  that  the  longer  a 
l^arasiticide  ointment  or  oil  is  kept  in  contact  A\dth  the 
scalp  the  better,  and  it  is  only  to  be  washed  off  when 
there  is  an  accumulation  of  scales,  or  for  pm^poses  of 
cleanliness.  But,  as  we  shall  see,  some  plans  of  treat- 
ment require  daily  washing  of  the  scalp. 

Ejyilat ion.— 'Epilation  is  mmecessary  in  recent  cases, 
but  serviceable  in  chronic  cases,  and  should  always  be 
practised  in  the  pustular  form.  It  is  by  no  means  as 
effectual  in  ringworm  as  in  favus,  because  the  hair  is 
so  brittle  that  it  breaks  off  when  palled  on  and  leaves 
its  spore-laden  root  in  the  scalp.  Still,  a  certain  num- 
ber of  the  roots  will  be  extracted,  and  this  wiU  have 
two  good  effects,  namely;  1.  The  removal  of  a  cer- 
tain amount  of  fungus  from  the  scalp;  and,  2.  The 
mouth  of  the  follicle  will  be  open  so  that  the  parasiti- 
cide may  gain  more  ready  access  to  its  deeper  portion. 
In  pustular  ringworm  the  hair  comes  away  readily, 


I'RICHOPHYTOSIS   CAPITIS.  225 

and  thus  relief  is  afforded  to  the  perifolUcuh'tis.  Epila- 
tion should  be  immediately  followed  by  the  application 
of  the  parasiticide. 

Treatment  of  recent  cases. — If  we  are  so  fortunate 
as  to  see  the  case  in  its  early  stage,  when  it  is  still 
superficial,  it  will  be  easy  to  effect  a  speedy  cure.  It 
is  in  such  cases  that  many  vaunted  remedies  have 
made  their  reputations.  One  of  the  most  reliable 
parasiticides  is  the  bichloride  of  mercury  in  alcohol, 
gr.  i — iii.  ad  1  j ;  or  even  stronger,  if  used  by  the  physi- 
cian, sopped  on  three  or  four  times  a  day.  Here  as 
elsewhere  the  best  means  of  applying  the  solution  is  a 
little  absorbent  cotton  on  a  wooden  toothpick,  or  any 
small  stick.  Caution  must  be  had  to  use  a  fresh  swab 
each  time,  otherwise  a  remnant  from  the  previous 
application  will  dry  on  the  swab,  and  we  soon  wiU. 
have  a  much  stronger  solution  than  we  want.  Levi- 
SEUR  (336  ap.)  uses  the  bichloride  in  tincture  of  ben- 
zoin, 1  in  300,  rubbing  it  in  with  a  tooth-brush,  after 
epilation.  As  soon  as  irritation  subsides  he  applies  a 
ten-per-cent  salicylic  acid  ointment.  Epilation  and 
the  bichloride  are  to  be  used  once  a  week,  and  the 
ointment  daily,  the  strength  of  each  to  be  slowly  in- 
creased to  double  that  used  at  first.  Kerley  (335  ap.) 
uses  two  grains  of  the  bichloride  dissolved  in  alcohol 
and  added  to  a  half  ounce  each  of  kerosene  and  olive 
oil,  followed  by  vaseline  or  simple  ointment,  and  re- 
peated when  irritation  subsides.  The  scalp  is  to  be 
frequently  washed  with  soap  and  water.  More  rapid 
results  were  obtained  by  alternating  a  saturated  tinc- 
ture of  iodine  with  the  bichloride  solution.  These  meth- 
ods are  also  useful  in  the  more  chronic  cases.  Vari- 
ous other  remedies  are  useful,  such  as  sulphurous  acid 
in  full  strength;  sulphuret  of  potassium,  3  ss-j,  water 
3  j  ;  hyposulphite  of  soda  3  iij,  water  3  j ;  sulphite  of 
soda  3  j-ii,  lard  3  i;  salicylic  acid,  two  to  five  per  cent. 


226  DISEASES   OF  THE   HAIR  AND   SCALP. 

in  castor  oil;  a  saturated  solution  of  boracic  acid;  car- 
bolic acid,  ten  to  twenty  per  cent,  in  glycerine,  varying 
with  the  age  of  the  child;  sulphur  ointment;  tinct.  of 
iodine,  and  others.  "V^^ien  the  disease  is  still  recent, 
but  the  hairs  have  become  invaded  and  a  characteristic 
patch  has  formed,  the  hair  is  to  be  cut  from  the  patches 
and  a  sHght  area  around  them.  In  this  stage  any  of 
the  just  mentioned  remedies  may  be  used.  It  is  in 
such  cases  that  chrysarobin  (chrysophanic  acid)  effects 
its  most  briUiant  cures.    Fayrer  (-I^G)  w^as  the  first,  in 

1874,  to  di^aw  the  attention  of  European  physicians 
to  its  use  in  the  treatment  of  ringworm  as  occurring  in 
India,  where  it  was  used  under  the  name  of  Goa  pow- 
der, araroba,  or  po'de  Baliia.  It  was  fii-st  used  in 
the  form  of  an  ointment,  and  Da  Silya  Lbia  (4 7-1)  in 

1875,  reported  excellent  results  from  one  composed  of 
Goa  powder,  2(i  gi^ains,  acetic  acid,  10  drops,  ointment 
of  benzoin,  one  ounce.  It  has  since  then  been  used 
successfully  in  the  form  of  an  ointment  of  five  to 
twenty  per  cent,  strength.  But  this  manner  of  apply- 
ing the  drug  on  the  scalp  is  objectionable,  as  it  is 
exceedingly  irritating,  and  frequently  causes  intense 
oedema  and  cellulitis  of  the  scalp  and  face.  The  best 
method  of  using  it  is  in  the  form  of  a  ''pigment" 
composed  of 


Chiysarobin, 

, 

10  parts, 

Flexible  coUodion, 

, 

90     " 

Castor  oil. 

• 

3  drops. 

This  is  to  be  painted  on  the  scalp  with  a  stiff  brush, 
and  renewed  as  often  as  the  film  loosens  or  scales  off. 

The  oleates  of  mercury  or  copper  in  five  to  ten  per 
cent,  strengths  according  to  the  age  of  the  child  are 
often  useful,  especially  the  first.  The  ointments  of 
the  ammoniate  and  red  oxide  of  mercury  are  favorites 


TRICHOPHYTOSIS  CAPITIS.  227 

with  many.  Tineture  of  iodine  will  sometimes  act 
brilliantly  in  these  cases,  and  the  combination  of  equal 
parts  of  iodine,  carbolic  acid,  and  chloral  hydrate,  as 
recommended  by  Cutler  (166  ap.),  is  excellent  both  in 
this  stage  and  in  the  more  chronic  ones. 

Treatment  of  chronic  cases. — The  chronic  cases  are  ex- 
ceedingly hard  to  cure,  and  medical  literature  is  rich  in 
methods  of  treatment.  The  first  requisite  to  success  is 
patience  both  on  the  part  of  physician  and  patient.  As 
there  frequently  is  need  for  changing  from  one  method 
of  treatment  to  another  before  the  case  is  cured,  it  has 
seemed  advisable  to  give  below  a  number  of  plans 
which  have  been  found  useful  by  competent  observers. 
Tilbury  Fox  (473  and  12)  recommends  epilation  fol- 
lowed by 

01.  cadini 3  iij. 

Sulphur, 3  iij, 

Lard  .        .        .        .         ad     Ij. 

M. 
He  directs  that  the  parasiticide  be  well  rubbed  in  for 
fifteen  or  twenty  minutes  every  morning  and  night. 
He  also  recommends  the  following  ointments: 

Sulphate  of  copper, 

Ammoniate  of  mercury,  aa  gr.xx  =•    1.50 

Oil  of  cade. 

Sulphur,  .         .  aa     3iij     =  12 

Lard,       .         .        .  ad     33       =  30 

M. 
If  this  is  too  strong  the  strength  is  to  be  reduced  by 
adding  more  lard.     Another  ointment  is: 

Oil  of  cade. 
Sulphur, 

Tinct.  iodine,  .        aa     3  iij      =     12. 

Carbolic  acid,    .         .         .       gr.xl    =       3. 
Lard,  .         .         .         .       3J         =30. 

M. 


22 S  DISEASES   OF   THE   HAIR  AND   SCALP. 

He  aims  at  producing  irritation  almost  to  the  point 
of  suppuration,  and  if  the  ahove  ohitments  do  not  ef- 
fect this,  he  prescribes  either: 

Corrosive  subhmate,  gi\  iv-vi.    =     .25-. 565 

Acetic  acid,        .  3  j  —    4. 

Lard,       .         ad.  3  j  =30 

M. 
or: 

Corrosive  subhmate,         gr.  vj      =         .565 

Tinct.  of  cantharides,       3  ss         =     16. 

Nitric  acid,       .         .  3  j  =4. 

Distilled  water,  ad    3  vj         =  200. 

M. 

When  there  are  but  a  few  small  spots,  he  blistei-s 
them,  and  continues  the  treatment  mitil  the  growth 
of  diseased  hairs  is  checked.  For  bhstering  fluids  he 
uses  acetic  acid,  or  Costar's  paste  (iodine  3  iij,  color- 
less oil  of  tar  ad  3  j),  applied  sparingly  to  small  sur- 
faces and  blotted  oif  when  they  begin  to  smart.  If 
much  irritation,  pain  and  swelling  follow  their  use,  he 
uses  a  poultice  for  one  or  two  hours.  Blistering  may 
be  repeated  every  four  to  six  days.  Then  epilation 
and  one  of  the  above  ointments,  or  the  lotion  is  contin- 
ued until  the  disease  is  cmed.  During  the  treatment 
the  hair  is  kept  either  well  greased,  or  soaked  with 
dilute  sulphurous  acid,  and  covered  ^\'ith  a  silk  cap.  In 
the  wards  of  children's  hospitals  he  directs  that  sul- 
phur be  burned  to  disinfect  the  air. 

E.  A.  Browx  (41  J:)  treats  his  cases  by  rubbing  the 
patches  with  rectified  oil  of  tar  and  covering  them 
with  a  layer,  one  eighth  of  an  inch  thick,  of  a  paste 
composed  of  tamiin,  iodine,  gum  arable  and  a  few 
drops  of  oil.  This  is  to  be  left  on  for  three  or  four 
days,  then  scraped  off,  and  re-applied. 

Sa3IL.  Gee  (434)  gives  the  following  directions  for 


TRICHOPHYTOSIS   CAPITIS.  229 

treatment.  1.  Cut  the  hair  everywhere  quite  close, 
and  keep  it  cropped  close.  2.  Wash  the  scalp  twice  a 
day  with  warm  water  and  soap.  3.  After  drying  inib 
well  into  the  scalp. 

Sulphocyanide  of  potassium,    ?  ss     =     15. 
Glycerine,  .         .         .       ij       =30. 

Water,        .         .         .         ,  ad  3  vij  =  200. 
M. 

4.  Keep  a  piece  of  lint  soaked  in  the  same  lotion  on 
the  scalp  day  and  night,  covering  it  with  oiled  silk 
and  a  calico  cap. 

Ladreit  de  Lacharriere  (446)  uses  in  chronic  cases 
croton  oil  followed  by  poultices,  only  a  small  place 
at  a  time  being  treated.  He  employs  a  cosmetic  pencil 
composed  of  equal  parts  of  croton  oil  and  white  wax; 
or  of  equal  parts  of  cocoa  butter  and  white  wax  with 
fifty  per  cent,  of  croton  oil.  The  mass  is  melted  and 
poured  into  hollow  cylinders  with  a  diameter  of  half 
an  inch.  A  cure  is  said  to  be  effected  in  from  six  to 
eight  weeks. 

Liveing  (453)  applies  the  tincture  of  iodine  in  double 
strength  every  day  in  extensive  cases,  and  follows  it 
with  the  ointment  of  the  nitrate  of  mercury;  or  the  red 
or  white  precipitate  ointment  with  sulphur;  or  a  ten 
per  cent,  oleate  of  mercury. 

Startin  (481)  advises  washing  the  part  with  soap 
and  water,  drying  and  applying  a  blistering  fluid.  After 
inflammation  has  subsided,  apply  equal  i)arts  of  oil  of 
cade,  creosote,  and  tincture  of  iodine,  and  a  lotion  of 
hyposulphite  of  soda  (  3  ij  ad  3  j).  If  the  skin  is  sore 
from  the  use  of  the  above,  apply  equal  parts  of  white 
precipitate  ointment  and  vaseline. 

Cottle  (416)  has  had  most  success  by  using  ^  ^liniment 
crotonis  "  to  produce  pustulation,  after  which  an  oint- 
ment or  lotion  of  salicylic  acid,  ten  to  forty  grains  to 


230  DISEASES   OF   THE   HAIU  AND   SCALP. 

the  ounce,  is  applied  two  or  three  times  a  day.  Some- 
times he  combines  oil  of  cade  or  carbolic  acid  with  the 
salicylic  acid.  If  an  eczematous  condition  is  present, 
he  combines  one  of  the  soothing  salts  of  zinc  or  mer- 
cury with  the  salicylic  acid. 

KiCHARDSON  (400)  has  used  ethylate  of  sodium  suc- 
cessfully in  a  case  of  chronic  ringworm. 

Morris  (460)  has  been  very  successful  wdth  the  fol- 
lowing: 

Thymol,         .         .  3  ss  =  2. 

Chloroform,  .  3  i j  =  8. 

Olive  oil,        .         .  3  vj  =     ad    30. 

M. 
The  amount  both  of  the  thymol  and  chloroform  is  to 
be  reduced  in  young  children  and  w  hen  the  disease 
tends  to  become  pustular.  The  oil  is  to  be  rubbed  in 
gently  two  or  three  times  a  day.  The  part  is  to  be 
w^ashed  w  ith  soap  and  water,  before  the  first  applica- 
tion, but  not  subsequently.  If  at  any  time  there  is 
the  slightest  irritation  the  rubbing  is  to  be  stopped  and 
the  oil  merely  smeared  on.  No  cap  should  be  w^orn  in 
the  house,  as  the  head  is  to  be  kept  cool. 

Harrison  (430)  by  a  series  of  experiments  upon  the 
comparative  power  of  various  substances  to  penetrate 
the  scalp,  found  that  the  most  powerful  combination 
of  remedies  was  to  apply  to  a  small  parf  of  the  diseased 
scalp  for  a  few  days  Solution  No.  1.,  as  follows; 

Iodide  of  potassium,  3  ss         =         2. 

Liquor  potassae,  .  3  j  =       30. 

M. 
on  pledgets  of  cotton.     This  is  followed  by  Solution 
No.  2. 

Corrosive  sublimate,  gr.  iij     =         .2 

Sweet  spirits  of  nitre,  vel. 

Water,  .         .         .  33  =30. 

M. 


TRICHOPHYTOSIS   CAPITIS.  231 

In  this  way  the  head  is  gone  over  several  times.  He 
has  treated  thirty  cases  hy  this  plan,  curing  them  in 
about  two  months.  His  theory  is  that  the  hquor 
potassa3  softens  the  hair  and  conveys  the  iodide  of 
potassium  to  its  root  and  bulb;  then  the  mercury  pene- 
trates to  the  same  place,  meets  the  iodide  of  potassium 
and  forms  the  biniodide  of  mercury  just  w^here  it  is 
wanted.  In  1889  Harrison  modified  his  procedure  on 
account  of  its  being  a  troublesome  one,  and  recom- 
mended that  the  patches  be  rubbed  every  night  and 
morning  with  the  following  : 


Potass,  caustic, 

,     .          gr  ix,        say    2. 

Ac.  carbolici. 

gr.  xxiv,    ''      5. 

Lanolini, 

01.  cocois, 

.    fill  3SS,             "    50. 

say 

33.33 
1. 

a 

100. 

M. 

And  the  whole  scalp  anointed  with  : 

1^  Ungt.  boricis, 

Ungt.  eucalypti.        .     aa    I  ij, 
01.  caryophilli,  .  3  ss, 

01.  cocois,  .        .ad  5  vi, 

M. 
FouLis  (428)  claims  to  cure  his  cases  in  seven  days  by 
cutting  the  hair  short  over  the  affected  parts,  or  off 
the  whole  head,  if  the  disease  is  extensive,  and  then 
rubbing  in  a  liberal  quantity  of  spirits  of  turpentine. 
When  the  scalp  begins  to  smart  it  is  to  be  washed 
with  warm  w^ater  and  a  ten  per  cent,  carbolic  soap 
It  is  then  to  be  dried  and  painted  with  two  or  three 
coats  of  the  tincture  of  iodine.  When  the  scalp  is  dry 
the  whole  head  is  to  be  anointed  with  carbohzed  oil, 
1  in  20.  The  treatment  is  to  be  repeated  once  or  twice 
a  day.  In  very  severe  cases  it  is  well  to  use  a  solution 
of  ten  grains  of  iodine  in  one  ounce  of  turpentine. 

Geo.T.  Elliot  (421:)  recommends  painting  the  part 
with  the  following: 


232  DISEASES   OF   THE   HAIR   AND   SCALP. 

Pyrogallol  (pyrogallic  acid),  3  ss-ij  =    2-S. 

Salicylic  acid,         .  .  3  ss  =2. 

Flexible  collodion,  .         3  ij  =     60. 
M. 

Lesser  (451)  has  found  a  ten  per  cent,  solution  of 
corrosive  sublimate  applied  twice  a  day  the  most  use- 
ful parasiticide. 

Kaposi  (19)  regards  as  specially  useful  the  following: 

Oil  of  birch,      .         .'  .         .         .  15. 

Tinct.  of  green  soap,  ...  25. 

Precipitated  sulphur,  ...  10. 

Spirits  of  lavender,  ...  50. 

Balsam  of  peru,         .  .         .         .          1.50 
M. 

Gamberini  (59)  recommends. 

Flowers  of  sulphur,  .         .         .         10. 

Camphor, 10. 

Lard, 30. 

M. 
Alder  Smith  (Y9)  has  often  been  successful  in  treat- 
ing ringworm  with, 

Boracic  acid,         .  3  iv  vel  q.s.    =      16. 

Common  ether,  §  v  .         =.150. 

Alcohol,       .  ad     Ixx       .         =    600. 

I        M. 

which  forms  a  saturated  solution  of  boracic  acid.  The 
hair  is  to  be  cut,  and  all  scurf  and  sebaceous  matter 
washed  from  the  patches  with  hot  water  and  soap. 
This  washing  is  to  be  repeated  every  morning.  After 
drying  the  head,  the  solution  is  to  be  well  dabbed  and 
pressed  into  the  hair  follicles  with  a  small  fine  sponge 
for  ten  minutes.  Eepeat  three  to  six  times  a  day. 
During  the  first  few  weeks  of  treatment  the  solution 
is  to  be  apphed  over  the  whole  head.  No  pomade 
should  be  used  during  this  treatment.  Sometimes  un- 
der this  plan  the  scalp  becomes  so  dry  that  the  hair 


TRICHOPHYTOSIS   CAPITIS.  233 

falls  out  of  itself,  and  leaves  bald  smooth  patches,  sini 
ilar  to  what  is  seen  in  alopecia  areata.  In  very  chronic 
cases,  and  especially  in  disseminated  ringworm,  his 
chief  reliance  is  upon  croton  oil.  In  the  disseminated 
variety,  a  minute  drop  is  placed  upon  every  stump,  or 
black  dot.  If  there  are  only  a  limited  number  of  these, 
the  oil  is  to  be  pressed  into  the  follicles  by  means  of  a 
line,  blunt  gold  pin.  A  pustule  results,  the  hair  loosens 
and  can  be  readily  pulled  out.  If  the  hair  breaks  off, 
the  oil  is  to  be  re-applied  when  the  pustule  has  healed. 
A  large  thin  poultice  worn  day  and  night  under  an  oil- 
skin cap  will  hasten  suppuration  and  aid  in  extracting 
the  hair.  In  a  chronic  case,  which  has  resisted  aU 
other  forms  of  treatment,  croton  oil  is  to  be  applied  to 
a  smaU  place,  not  much  larger  than  a  ten  cent  piece, 
at  a  time  and  followed  by  a  poultice.  If  one  applica- 
tion does  not  give  rise  to  suppuration,  repeat  until  arti- 
ficial kerion  is  produced,  the  scalp  being  swollen,  ten- 
der, puffy^  and  pustular.  The  hairs  are  now  loosened 
and  are  to  be  removed,  and  soothing  remedies  applied, 
as  in  kerion.  A  second  patch  is  to  be  attacked  as  soon 
as  the  first  one  is  progressmg  favorably,  and  so  all  dis- 
eased portions  are  to  be  treated.  This  plan  is  to  be 
kept  for  a  last  resort.  If  a  bald  spot  remain  after  the 
use  of  croton  oil,  a  stimulating  lotion  is  to  be  ordered. 

The  same  author  recommends  the  removal  of  obsti- 
nate disseminated  diseased  hairs  by  electrolysis,  which 
of  course  destroys  the  follicle. 

Leftwich  (450)  advises  cutting  the  hau-  close  from  and 
around  the  patch,  and  painting  the  scalp  with  an  alco- 
holic solution  of  the  iodide  of  mercury,  made  by  add- 
ing calomel  to  tincture  of  iodine,  and  using  the  super- 
natant colorless  fluid.  When  the  soreness  caused  by 
it  has  passed  off,  an  iodine  plaster  is  to  be  applied,  and 
left  on  for  a  week  or  so.  This  plaster  is  made  by  add- 
ing a  half  drachm  of  soHd  iodine  to  an  ounce  of  plaster 


234  DISEASES   OF   THE   HAIR  AND   SCALP. 

mass,  and  spreading  it  on  kid.  By  this  treatment  the 
doctor  expects  to  cure  his  cases  in  a  month. 

Charon  and  Gevaert  (321  ap.)  commend  the  treat- 
ment by  galvanism  proposed  by  Eeynolds,  of  Chi- 
cago— that  is,  by  saturating  the  electrode  of  the  posi- 
tive pole  v/ith  a  three-  to  five- per  cent,  solution  of 
bichloride  of  mercury,  anil  applying  it  to  the  diseased 
spot  for  ten  or  fifteen  minutes.  Pukdon  has  used 
^ith  benefit  an  ethereal  tincture  of  the  seeds  of  cro- 
ton  tiglium  with  sahcylic  acid.  A  neat  and  often 
rehable  method  of  treatment  is  that  devised  by  DocK- 
RELL  (322  ap.).  The  patch  is  to  be  shaved  and  washed 
with  a  five-per  cent,  hydronapthol  soap  and  hot  wa- 
ter. After  drying  the  patch  it  is  to  be  covered  with 
narrow  strips  of  ten-per-cent.  hydronapthol  plaster, 
overlapping  at  the  edges  and  going  beyond  the  peri- 
phery of  the  patch.  This  is  to  be  covered  with  ten 
per  cent,  hydronapthol  gelatin.  After  four  days  the 
plaster  is  to  be  removed,  the  washing  and  drying  re- 
peated, and  a  twenty-per-cent.  plaster  used  in  the 
same  way.  This  is  to  be  left  on  for  one  week,  and 
followed  by  a  ten-per-cent  plaster  for  ten  days. 

Hutchinson  (332  ap.)  has  the  scalp  washed  twice  a 
Aveek  with  one  drachm  of  liquor  carbonis  detergens  in 
one  pint  of  hot  water.  He  shaves  tlie  patch,  or  has 
the  hair  cut  close,  and  applies  every  morning  and 
evening,  or  only  in  the  evening  : 

I^  Chrysarobin,     .         .  3i, 

Hydrarg.  ammon.,  .         gr.  xx. 

Lanolin  i,  .         .         3  i, 

Adipis  benzoat.,       .   ad  3  ij, 

Liq.  carbonis  detergens,  ^x, 
M. 

"XMien  the  case  seems  to  be  cured  the  same  ointment, 
of  less  strength,  is  to  be  continued  for  six  months. 


say 

12. 

i( 

4. 

u 

12. 

ii 

100. 

ii 

2. 

TRICHOPHYTOSIS  CAPITIS.  235 

Butte  (320  ap.)  has  the  scalp  washed  every  second 
day  with  a  spray  of  hot  water,  and  then  apphes  proto- 
chloride  of  iodine  (ten  per  cent.)  in  lanohne.  If  epi- 
lation is  thought  to  be  necessary  he  paints  the  patch 
with  many  layers  of  the  following  : 

n  Alcohol  at  95°,       ....  12. 

Iodine,           .        .        .        .        .  .75 

Dissolve,  and  add  : 

Collodion, 35. 

Venetian  turpentine,    .        .        .  1.50 

Castor  oil, 2. 

M. 

This  is  to  be  repeated  every  day  for  three  or  four 
days  ;  then  the  border  of  the  artificial  skin  is  to  be 
loosened  and  the  whole  gently  torn  away.  Then 
parasiticides  are  to  be  used  until  another  epilation  is 
necessary. 

QuiNQUAUD  (350,  351  ap.)  recommends  lightly  scrap- 
ing the  patches  with  a  curette  at  intervals  of  five  to 
eight  days,  and  applying  twice  a  day  : 


Hydrarg.  biniod.. 

20 

Hydrarg.  bichlorid.,     . 

1 

Alcohol  at  90°,      . 

40 

Aquae  dest.. 

.       250, 

M. 

On  the  fifth  or  sixth  day,  after  scraping,  apply  to 
patches  and  all  over  the  scalp  : 

1^  Chrysarobin, 

Ac.  salicylici, 

Ac.  boricis,     .         .         .         .         aa      2. 

Vaselini,  ....  100. 

M. 


236  DISEASES   OF  THE  HAIR  AND   SCALP. 

The  head  is  to  be  kept  covered  with  a  rubber  or 
cloth  cap  held  in  place  by  a  zinc  or  bismuth  gelatin 
paste.  The  ointment  is  to  be  used  for  one  or  two 
days,  and  then  the  lotion  as  before. 

Yidal's  method,  according  to  Eloy  (327  ap.),  is  to 
bathe  with  spirits  of  turpentine,  and  then  apply  tinc- 
ture of  iodine  to  a  limited  portion.  The  scalp  is  to  be 
kept  anointed  with  vaseline  every  other  day,  and  cov- 
ered with  a  closely  fitting  cap. 

Carrere  (50  ap.)  gives  Besnier's  treatment  as  con- 
sisting in  epilating  for  six  to  eight  millimetres  about  the 
patch,  curetting  it,  washing  wath  tar,  salicylic  acid,  or 
sulphur  soap,  and  covering  with  emplastrum  Vigo. 
Hallopeau  has  the  patches  washed  with  sapo  viridis, 
and  then  rubs  in 

5  Alcohol, 125. 

Spts.  turpentine,           ...  25. 

Liq.  ammon.,        ....  5. 
M. 

and  applies  half  an  hour  afterward  vaseline  with  one 
per  cent,  of  iodine.  A  rubber  cap  is  to  be  constantly 
worn,  and  the  vaseline  is  to  be  renewed  at  night. 

D'Audraix  (35  ap.)  apphes  tincture  of  iodine  once  a 
day,  or  twice  if  not  too  irritating.  Every  second  day 
he  removes  the  destroyed  epithelium.  AVhen  the 
parts  have  become  smooth  he  epilates  and  scrapes 
them,  and  makes  intradermic  injections  of  the  fol- 
lowing : 


Hydrarg.  bichlor., 

.01 

Ac.  tartaric,    . 

.40 

Cocaini  liydrochlorat., 
Alcohol, 

1. 

Aquae  destill., 
M. 

.    aa  30. 

TRICHOPHYTOSIS   CAPITIS.  237 

The  syringe  needle  is  to  be  directed  obliquely  and 
deep  under  the  skin.  One  drop  of  the  fluid  is  to  be 
pressed  out  at  each  insertion,  and  the  insertions  are  to 
be  made  close  together.  He  has  made  as  many  as 
fifty  at  one  sitting.  Twelve  days  after  the  injection 
the  patches  are  white,  smooth,  and  absolutely  bald, 
and  he  expects  the  hair  to  appear  within  from  three 
to  eight  weeks. 

The  rapidity  of  cure  will  depend  largely  upon  the 
thoroughness  w^ith  which  directions  are  followed,  and 
the  physician  should  make  the  applications  himself 
during  the  first  few  days,  until  some  one  of  the  family 
becomes  properly  trained.  The  results  are  often  best  in 
hospitals  because  of  the  constant  supervision  of  the 
house  physicians  and  the  skillful  manipulations  of  the 
trained  nurses. 

After  a  case  has  recovered  from  trichophytosis  a  dry 
and  scaly  condition  of  the  scalp  may  be  left.  This 
condition  may  readily  be  cured  by 

Hydrarg.  ammon      .  .  .         3ij  =  3. 

Hydrarg.  chlor.  mitis  .  .         3iv=  6. 

Vasehne    .        .        .  .  ad    §1  =3u. 
M. 

a  favorite  formula  of  Dr.  E.  B.  Bronson  of  New  York. 
Or  a  sulphur  ointment  may  be  used  of  the  strength  of 
one  drachm  to  the  ounce. 

When  to  stop  treatment  is  a  very  important  matter 
to  determine.  The  mistake  is  often  made  of  stopping 
as  soon  as  the  hair  is  growing  fairly.  We  should  sus- 
pend treatment  as  soon  as  the  scalp  is  no  longer  scurfy, 
the  hair  is  growing  healthily,  the  microscope  no  longer 
shows  the  presence  of  fungus  in  the  hair,  and  there  are 
no  stumps  to  be  found  in  the  scalp.  The  patient  should 
be  kept  under  observation  for  a  few  months,  and  if 
these  same  conditions  are  preserved  he  may  be  dis- 
charged as  cured. 


238  DISEASES   OP  THE   HAIR  AXD   SCALP. 

Over-treated  cases  are  sometimes  met  with,  either 
too  strong  remedies  having  been  employed,  or  proper 
riemedies  continued  too  long.  The  condition  present  is 
usually  one  of  eczema,  the  original  disease  perhaps 
having  been  cured.  By  suspending  all  treatment  from 
time  to  time  we  will  easily  avoid  this. 

Progkosis. — The  prognosis  is  good,  though  the  dis- 
ease is  often  very  rebellious  to  treatment.  A  too 
speedy  cure  should  not  be  promised,  and  three  to  six 
months  must  often  be  given  to  the  treatment  of  a 
chronic  case.  It  must  be  borne  in  mind  that  the  dis- 
ease is  in  most  cases  self-hmited,  and  the  most  mveter- 
ate  cases  tend  towards  spontaneous  recovery  with  the 
approach  of  adult  yeai*s,  rarely  lasting  later  than  the 
fifteenth  or  sixteenth  year.  This  should  prevent  us 
from  makuig  use  of  such  remedies  as  croton  oil  except 
when  other  things  have  failed,  as  it  produces  at  tunes 
permanent  baldness  if  not  carefully  employed.  Cases 
have  been  known  to  spontaneouly  heal  in  from  one  to 
three  years.  Baldness  rarely  follows  the  disease  ex- 
cepting as  the  result  of  ti'eatment. 

Granuloma  tricliophyticnm. — Under  this  title  Ma- 
JOCCHi  (458),  in  1883,  described  a  form  of  ringworm  at- 
tacking hairy  regions  which  differed  from  sycosis  and 
kerion,  and  consisted  oi  round  tmnors  of  normal  skin- 
color,  painless,  non-scaly,  surrounded  by  a  colorless 
areola,  of  the  size  of  a  half  walnut,  at  first  elastic, 
then  soft  and  fluctuating  like  an  abscess.  In  the  middle 
of  each  is  a  trichophytic  hair,  or  a  filament  of  fungus. 
Histologically  the  tumors  have  the  charactei^  of  a  sub- 
cutaneous gi'anuloma,  young  granulation  cells  with 
blood-vessels  and  giant  ceUs.  Majocchi  believes  that 
in  these  cases  the  fungus  penetrated  into  the  corium 
through  the  hair  foUicle  and  sebaceous  gland. 


CHAPTEE  XIII. 

KERION. 

Synonyms: — Trichomykosis  capillitii  (Auspitz);  Ves- 
pajo  del  Capillizio,  Vespajo  tricofitico  del  Capillizio 
(Ital).     Tinea  kerion;  KerioiiCelsi. 

Definition. — A  more  or  less  chronic  inflammation 
of  the  hairy  scalp,  characterized  hy  the  formation  of  a 
prominent,  boggy,  uneven  swelling,  studded  with 
numerous  foramina  out  of  which  oozes  a  sticky, 
mucoid  substance.  The  tumor  at  times  undergoes 
suppuration,  and  generally  follows  upon  ringworm  of 
the  scalp. 

Symptoms. — Kerion  derives  its  name  from  a  Greek 
word  meaning  a  honeycomb.  The  Italian  name  signi- 
fies a  wasp  nest.  It  has  generally  been  regarded  as  a 
stage  of  ringworm  of  the  scalp,  but  it  is  better  to  look 
upon  it  as  a  form  of  that  disease  rather  than  a  stage, 
as  it  may  be  produced  artificially  and  independently 
of  trichophytosis.  It  is  analogous  to  the  nodular 
swellings  met  with  in  trichophytosis  barba?.  Tilbury 
Fox  (5(12),  in  ISGG,  first  identified  kerion  as  a  form  of 
ringworm. 

As  ordinarily  met  with  the  disease  or  condition  fol- 
lows upon  a  simple  patch  of  ringworm.  The  affected 
part  becomes  red,  oedematous,  swollen,  and  boggy;  it 
may  be  purplish  in  color.  Its  surface  is  glazed,  un- 
even, and  studded  with  a  number  of  yellowish  suppur- 
ating points,  or  with  foramina  out  of  which  oozes  a 
sticky,  gelatinous,  viscid,  transparert  fluid.  At  times 
if  the  inflammatory  process  is  more  intense,  the  swell- 


240 


DISEASES  OF  THE  HAIR  AXD  SCALP. 


ing  may  reach  considerable  size,  and  instead  of  a  mu- 
coid fluid  escaping  from  the  foramina,  true  suppura- 
tion may  take  place  attended  with  a  sero-purulent  dis- 
charge. The  amount  of  the  discharge  is  in  proportion 
to  tlie  amount  of  inflammation  present,  and  the  depth 
to  which  the  process  goes.     The  swelling  is  rounded  or 


Kerion. 


oval  in  shape,  and  varies  in  size;  usually  it  is  one  or 
two  inches  in  diameter,  but  it  may  become  as  large  as 
a  turkey's  egg. 

The  hair  on  the  affected  part  at  first  has  the  charac- 
teristic appearances  of  that  of  ringworm,  when  kerion 
follows  that  disease,  being  broken  off,  and  presenting 
stumps.  The  pustules  of  the  early  stage  of  the  disease 
form  about  the  hairs  at  their  exit  from  the  scalp. 
Later  the  hairs  loosen,  and  are  easily  plucked;  as  the 
inflammation  progresses,  they  fall,  and  from  the  open- 
ings of  the  hair-foUicles  the  mucoid  or  sero-pumlent 


KERION.  2il 

discharge  takes  place.  If  the  disease  is  not  properly 
managed,  or  if  the  inflammation  is  very  intense,  per- 
manent baldness  may  result  from  destruction  of  the 
hair  follicles. 

The  subjective  symptoms  are  more  or  less  pain;  ten- 
derness on  pressure;  at  times  itching  and  burning. 
The  course  of  the  disease  is  chronic,  and  it  may  last  a 
very  long  time.  At  times  the  posterior  cervical  glands 
are  enlarged,  as  is  common  in  inflammatory  diseases  of 
the  scalp. 

Etiology.  —The  disease  is  rare.  I  have  met  with  it 
only  three  times  in  six  thousand  cases.  It  occurs  in 
all  classes  of  society,  but  affects  children  especially. 
The  scrofulous  habit  or  a  poor  constitution  favor  this 
form  of  inflammation,  though  it  may  occur  in  healthy 
subjects.  The  exciting  cause  is,  in  most  cases,  the 
trichophyton  fungus  passing  deep  down  into  the  hair- 
follicles.  It  may  be  produced  by  over  treatment  of  a 
case  of  ringworm  of  the  scalp ;  or  by  the  application 
of  irritants  to  the  scalp  quite  independently  of  ring- 
worm; or  it  may  foUow  eczema  or  sycosis  of  the  scalp. 
According  to  Majocchi  (503)  this  condition  is  some- 
times met  with  in  favus. 

Pathology.— When  due  to  the  trichophyton  tonsu- 
rans, the  fungus  penetrates  deeply  into  the  hair-follicles 
and  there  sets  up  an  inflammation.  This  will  vary  in 
intensity  with  the  irritation  produced.  According  to 
Atkinson  (499),  if  the  irritation  goes  only  to  a  certain 
extent  there  will  result  a  purely  catarrhal  inflamma- 
tion of  the  hair-follicles,  and  the  production  of  a  mu- 
coid secretion.  If  the  irritation  is  greater,  a  suppura- 
tive inflammation  will  be  established,  and  there  wiU  be 
a  sero-purulent  discharge.  Eobinson  (33)  says,  that 
''  in  tinea  kerion  the  glands  of  the  skin  seem  to  be  af- 
fected as  well  as  the  hair-follicles,  and  pour  out  a  mu- 
coid secretion.     In  this  fonn,  though  there  is  no  true 


242  DISEASES  OF  THE   HAIR  AND   SCALP. 

suppurative  process,  the  inflammation  in  the  given 
area  is  so  general,  deep,  and  long-continued  that  the 
follicles  are  destroyed,  and  permanent  alopecia  results. " 
Majocchi  (503)  found  the  parasite  in  the  hair- follicle, 
along  the  hair- shaft,  and  in  the  connective  tissue 
^around  the  hair-follicle;  the  folhcles  filled  with  epithe- 
hal  cells,  pus  corpuscles,  spores,  and  mycelia,  and  the 
sebaceous  glands  and  skin  in  the  neighborhood  in- 
flamed. 

We  need  not  here  describe  the  trichophyton  fungus, 
as  that  has  been  done  in  the  preceding  chapter.  If 
hairs  are  j^lucked  from  a  non-suppurative  patch  of 
kerion  the  fungus  will  be  found  in  abundance  in  them 
and  their  sheaths.  If  suppuration  is  active  in  the 
patch  the  fungus  may  be  destroyed,  and  it  may  not  be 
found  in  the  hairs. 

Diagnosis. — Kerion  is  most  apt  to  be  mistaken  for 
a  subcutaneous  abscess.  It  must  also  be  diagnosed 
from  a  papilloma  of  the  scalp,  from  a  gummatous 
tumor,  a  sebaceous  cyst  and  a  fatty  tumor. 

An  abscess  is  not  preceded  by  ringworm,  has  no  his- 
tory of  any  irritation  directly  apphed  to  the  part,  and 
may  arise  without  any  antecedent  disease  of  the  scalp. 
Kerion  is  commonly  preceded  by  a  ringworm,  or  there 
is  a  history  of  some  antecedent  disease,  or  the  applica- 
tion of  some  iri'itant  to  the  part.  An  abscess  as  a  rule 
is  very  painful,  and  the  patient  experiences  a  sensa- 
tion of  throbbing  in  the  part.  Kerion  is  nmch  less 
painful  and  sometimes  itchy.  Abscesses  occur  in  sub- 
jects of  lowered  vitality.  Kerion  often  occurs  in  the 
otherwise  robust.  The  formation  of  an  abscess  is  ac- 
companied by  chilhness,  fever,  and  general  malaise. 
These  symptoms  are  absent  in  kerion.  An  abscess 
when  ripe  shows  fluctuation  and  contains  pus.  Kerion 
is  boggy  to  the  feel  and  generally  does  not  contain  pus. 
There  is  no  discharge  from  an  abscess  unless  it  has 


KERION.  243 

been  opened  either  naturally  or  by  the  knife,  and  then 
it  gives  exit  to  pus.  Kerion  pours  out  a  mucoid  secre- 
tion from  numerous  foramina.  In  the  hairs  pulled 
from  over  an  abscess  the  trichophyton  fungus  is  want 
ing.  In  the  hairs  pulled  from  a  kerion  the  fungus  is 
usually  present,  or  it  will  be  found  in  hairs  from  other 
parts  of  the  head. 

The  other  diseases  mentioned  above  should  not  be 
confounded  with  kerion.  A  papilloma  is  non-inflam- 
matory, exceedingly  chronic,  firm  to  the  touch,  and 
has  no  discharge.  A  gumma  is  usually  accompanied  by 
other  signs  of  syphilis,  and  tends  to  break  down  and 
ulcerate.  A  sebaceous  cyst  is  slow  in  its  groAvth;  the 
skin  over  it  is  normal;  it  shows  no  great  tendency  to 
break  down,  and  if  opened  it  gives  vent  to  a  fetid, 
cheesy  mass.  A  fatty  tumor  is  a  chronic  swelling, 
freely  movable,  rather  elastic  to  the  touch,  and  the 
skin  over  it  is  normal. 

Prognosis. — The  disease  is  curable,  although  some- 
times wath  difficulty.  The  chief  thing  to  be  feared  is 
the  occurrence  of  permanent  baldness,  and  this  will  oc- 
cur in  some  cases  even  with  the  greatest  care. 

Treatment. — The  first  thing  to  which  we  should 
give  attention  is  to  the  thorough  epilation  of  the  af- 
fected part.  This  will  sometimes  save  the  hair  from 
destruction  and  prevent  baldness.  It  will  remove  a 
certain  amount  of  the  fungus  from  the  scalp,  and  open 
up  the  foUicles  for  the  escape  of  the  mucoid  or  sero- 
purulent  secretion. 

The  subsequent  treatment  wiU  depend  upon  the 
causation  of  the  case.  If  it  is  due  to  the  appHcation  of 
an  irritant,  such  irritant  must  be  stopped,  and  a  poul- 
tice, hot  w^ater,  or  some  mild  emollient  dressing  ap- 
plied. Mild  antiphlogistic  remedies  are  also  indicated 
in  cases  complicating  eczema  and  sycosis.  But  as 
most  cases  are  due  to  the  trichophyton  tonsurans  we 


244  DISEASES   OF   THE   HAIR   AND   SCALP. 

should  at  once  apply  antiparasitics,  just  as  in  scabies, 
for  instance,  ws  use  sulphur,  no  matter  how  imtated 
the  skin  may  be.  This  is  advised  against  by  some  au- 
thorities, bift  most  are  in  its  favor.  The  antiparasitics 
mentioned  in  the  chapter  on  trichophytosis  capitis  are 
useful  in  keiion.  Of  them  dilute  sulphurous  acid; 
a  solution  of  bichloride  of  mercury,  a  grain  to  the 
ounce  ;  hyposulphite  of  soda,  one  or  two  drachms  to 
the  ounce  of  water  ;  carbolic  acid,  twenty  to  thirty 
grains  to  the  ounce  of  water,  are  perhaps  the  best. 
These,  joined  to  epilation,  ^ill  generally  result  in  a 
speedy  cm^e. 


OHAPTEE  XIY. 

TRICHOPHYTOSIS  BARB^. 

Synonyms. — Tinea  sycosis;  Sycosis  parasitica,  seu 
parasitaria,  seu  contagiosa,  seu  menti;  Tinea  barbae; 
Trichomykosis  barbae  (Auspitz);  Dermatomykosis  bar- 
bae nodosa;  Mentagra;  Herpes  tonsurans  barbae;  Tricho- 
phytie  sycosique,  Sycosis  jmrasitaire  (Fr.);  Teigne- 
mentagra,  (Bazin);  Parasitische  Bartfimie,  (Ger);  Par- 
asitic mentagra,  Ringworm  of  the  beard.  Barber's  itch 
(Eng.);  Sicosi  parasitaria  (It.). 

Definition. — A  contagious  parasitic  disease  of  the 
hair  of  the  face  and  neck,  caused  by  the  trichophyton 
tonsurans,  which  invades  the  hair  foUicles,  disinte- 
grates the  hair,  sets  up  a  peri-follicuhtis,  with  inflam- 
mation of  the  skin  and  subcutaneous  tissues,  and  gives 
rise  to  the  formation  of  pustules,  tubercles  and  nodular 
swellings.  It  runs  a  chronic  course,  is  rebellious  to 
treatment,  and  may  cause  permanent  baldness. 

Symptoms.— This  is  the  barber's  itch  proper,  and 
presents  different  appearances  in  accordance  with  the 
depth  to  which  the  parasite  has  penetrated  and  the 
amount  of  irritation  it  causes.  It  begins  as  an  ordin- 
ary ringworm  of  the  body,  a  reddish,  more  or  less  circu- 
lar scaly  patch,  appearing  on  the  bearded  portion  of 
the  face,  which  is  either  scarcely  raised  above  the 
surface  of  the  skin,  or  has  its  circumference  markedly 
raised,  and,  it  may  be,  vesicular  or  pustular,  while  its 
centre  is  scaly.  In  some  cases,  under  appropriate 
treatment,  the  process  may  go  no  further;  and  some- 
times it  stops  here  spontaneously. 


246 


DISEASES  OF  THE   HAIR  AND   SCALP. 


In  most  untreated  cases  the  parasite  penetrates  the 
hau'-foUicles,  sets  up  a  folhcuhtis,  and  peri-foUicuhtis, 
and  more  or  less  inflammation  of  the  skin  and  suhcu- 
taneous  tissues,  giving  rise  to  the  formation  of  pustules, 
papules,  tubercles,  nodular  swellings,  and,  rarely,  ab- 
scesses. According  to  Behrend  (33)  it  takes  about  four- 
teen days  for  the  fungus  to  penetrate  the  deeper  parts 
of  the  skin.     The  hak  is  early  affected  like  as  in  the 


Trichophytosis  Barbae. 

other  forms  of  rmgworm,  becoming  dry,  brittle, 
twisted,  and  broken  off.  Over  the  tubercles  and 
nodules  the  hair  may  be  extracted  with  the  gi'eatest 
ease  and  without  pain  to  the  patient,  and  it  may  fall 
spontaneously.  The  hair  roots  may  be  dry,  or  they 
may  be  swollen  and  boggy. 

A  characteristic  case  of  the  disease  presents  the 
follo^^^ng  features:  Upon  the  chin,  neck,  and  sub- 
maxillary regions,  we  find  a  number  of  tubercles  and 


TRICHOPHYTOSIS   BARB^.  247 

nodules,  varying  in  size  from  a  split  pea  to  a  half  cherry. 
These  are  irregularly  shaped,  for  the  most  part  romided; 
are  prominently  raised  above  the  surface  of  the  skin, 
it  may  be  to  the  height  of  half  an  inch;  and  show  a 
marked  tendency  to  group  in  segments  of  circles  and 
to  form  patches.  There  may  be  one  group  of  nodules 
or  there  may  be  half-a-dozen  or  more.  The  nodules 
themselves  have  a  congested,  purphsh  look.  They  are 
either  hard  and  scaly,  or  they  discharge  a  thick  sticky 
fluid  from  many  follicular  openings,  or  they  suppurate. 
The  hair  over  them  is  broken  or  stubbed,  or  it  has 
fallen  out  so  that  the  affected  parts  are  more  or  less 
bald.  The  skin  between  the  separate  groups  is  usually 
unaffected,  as  also  may  be  the  case  between  the  indi- 
vidual nodules.  But  very  often  the  skin  over  the 
patches  is  reddened  and  crusted,  and  there  are  a  num- 
ber of  pustules  about  the  hairs  at  their  exit  from  their 
foUicles.  In  some  cases  the  amount  of  pustulation  is 
so  great  that  the  appearances  are  very  hke  those  found 
in  sycosis,  and  when  the  crusts  are  removed  the 
affected  part  presents  that  moist,  raw  surface,  studded 
^\  ith  numerous  points  discharging  a  glutinous  material, 
which  suggested  the  name  of  <T'jy.o'^,  a  fig. 

Subjective  symptoms  may  be  wanting;  commonly 
some  itching  and  burning  are  experienced;  sometimes, 
if  the  inflammation  runs  high,  there  will  be  more  or 
less  pain,  and  even  some  constitutional  distiu'bance  in 
the  form  of  chills,  slight  fever  and  loss  of  appetite.  I.i 
the  vast  majority  of  cases,  the  patients  are  more  trou- 
bled by  the  unsightUness  of  the  disease  than  by  any 
physical  discomfort. 

The  disease  commonly  affects  the  chin,  neck,  and  sub- 
maxillary regions.  In  most  cases  the  upper  parts  of 
the  cheeks  are  spared,  and  the  upper  lip  is  very  rarely 
invaded  even  in  the  worst  cases.  The  malady  may 
bo  limited  to  a  single  patch,  or  to  one  side  of  the  face^ 


24S  DISEASES   OF   THE   HAIR   AXD   SCALP. 

or  may  iii\*(3lve  the  whole  bearded  portion  of  the  face. 
It  is  very  chronic  in  its  course  when  it  once  becomes 
deep-seated.  At  times  it  may  pass  over  from  the 
hairy  to  the  non-hairy  contigaous  parts. 

Etiology. — The  trichophyton  fungus  is  solely  re- 
sponsible for  tliis  disease.  As  it  affects  the  bearded 
portion  of  the  face,  men  are  naturally  its  victims.  It 
is  most  frequently  met  with  in  men  of  early  and  mid- 
dle manhood,  say  from  the  twentieth  to  the  forty-fifth 
year.  The  same  idiosyncrasy  is  shown  in  the  suscep- 
tibility to  this  as  to  other  forms  of  ring-worm,  not  every 
man  being  capable  of  taking  it.  Hyde  (IS)  has  met 
Avith  it  more  often  in  men  with  light  hair  and  eyes,  and 
Hght  brown,  reddish  or  sandy  beard.  It  occurs  most 
often  aniong  those  who  shave,  and  especially  those  who 
are  shaved  by  barbers.  All  classes  are  attacked  by  it, 
but  it  is  more  common  amongst  the  poor. 

The  barbe:r's  damp  towels,  and,  may  be,  his  fingei^, 
are  the  most  active  agents  in  spreading  the  disease. 
The  shaving  biTish  and  razor  may  convey  the  fungus, 
though  if  the  water  used  in  shavmg  is  hot,  the  danger 
is  reduced.  The  razor  strop  and  mug  may  be  mediate 
carriers  of  infection.  The  disease  may  also  be  acquired 
du'ectly  from  animals,  from  cases  occumng  on  other 
indi\4duals,  or  may  be  conveyed  from  other  pai-ts  of 
the  body  to  the  beard.  The  health  of  the  pei^on  has 
no  influence  upon  the  disease. 

Trichophytosis  barbae  is  not  very  common.  In 
Boston,  White  met  with  it  thirty-eight  times  in  5,000 
cases.  In  Xew  York,  Bulkley  had  twenty-four  cases 
in  8,000.  In  Glasgow,  Anderson  saw  it  but  eighteen 
times  in  10,000  cases.  It  is  said  by  Duhrixg  (10)  to 
be  more  common  in  France,  and  rare  in  Vienna.  In 
Germany  it  is  quite  common,  because,  as  McCall 
Anderson  (501)  says,  ' '  the  men  there  kiss  each  other, 
and  go  dailv  to  be  shaved." 


TRICHOPHYTOSIS    BARB^.  2.1:9 

Pathology. — We  need  not  say  anything  here  about 
the  appearances  of  the  fungus  in  the  hair  and  scales, 
as  they  are  the  same  as  in  ringworm  of  the  scalp.  Kob- 
INSON,  (33)  has  found  it  in  the  matrix  of  the  hair  and 
between  the  hair-sheaths.  If  there  is  much  suppura- 
tion it  will  destroy  the  fungus,  and  none  may  be  found 
in  many  hairs  examined.  There  is,  as  a  rule,  more 
mycelia  in  the  hairs  of  ringworm  of  the  beard  than  in 
the  same  disease  of  the  scalp.  At  times  httle,  round, 
ghstening  bodies  are  seen  in  the  hairs,  in  their  frayed- 
out  ends,  and  in  the  remains  of  the  root-sheath,  which 
are  regarded  by  Lang  (520)  as  the  product  of  disorgani- 
zation, but  not  of  the  fungus.  He  affirms  that  the 
proper  fungus  remnants  are  cubical,  large,  glistening 
masses,  either  simple  or  forked.  It  is  curious  to  note 
that  before  the  identity  of  the  parasite  of  tinea  sycosis 
with  that  of  trichophyton  tonsurans  was  proven,  it 
was  called  the  microsporon  mentographytes. 

The  severity  of  the  symptoms  varies  with  the 
amount  and  seat  of  the  fungus,  and  the  manner  in 
which  the  tissues  react  to  it  as  a  foreign  body,  which  is 
somewhat  a  matter  of  idiosyncrasy.  That  tubercles 
and  nodular  swellings  are  found  here  and  not  in  the 
same  disease  as  it  occurs  upon  the  scalp,  is  due  to  the 
amount  and  looseness  of  the  subcutaneous  connective 
tissue.  Lang  (520)  beheves  that  their  presence  is  ac- 
counted for  by  the  inflammation  and  suppuration  of 
the  sebaceous  glands,  which,  in  the  bearded  portion 
of  the  face,  lie  m  very  loose  connective  tissue,  and  are 
freely  supplied  with  blood-v*essels  which  anastomose 
around  them.  Tilbury  Fox  (12)  has  drawn  attention 
to  the  appearances  of  trichorrhexis  nodosa  which  the 
hair  sometimes  presents  in  this  disease.  This,  how- 
ever, is  not  peculiar  to  trichophytosis  barbae. 

Diagnosis.— The  differential  diagnosis  is,  mainly, 
between  trichophytosis  barbae,  and  sycosis  and  pustular 


250  DISEASES   OF   THE   HAIR  AND  SCALP. 

eczema.  Sometimes  a  large  papular  or  tubercular 
syphilide,  an  indurated  acne,  or  an  epithelioma  will 
need  to  be  differentiated.  If  the  characteristics  of 
the  disease  as  already  given  are  borne  in  mind,  there 
should  be  little  difficulty  in  making  a  diagnosis.  The 
finding  of  the  fungus  in  the  hair  is  decisive  against 
any  of  the  diseases  mentioned  above. 

Si/cosis  affects  all  parts  of  the  face,  notably  the 
upper  hp,  and  is  entirely  devoid  of  nodular  swellings. 
Trichoj^hytosis  barbae  affects  by  preference  the  chin 
and  submaxillary  regions,  spares  the  upper  lip  as  a 
rule,  and  has  large  tubercles  and  nodules  which  tend 
to  group.  Sycosis  is  an  active  inflammation,  and  pre- 
sents many  pustules  pierced  by  hairs.  Trichophytosis 
barbcB  is  a  more  sluggish  inflammation,  and  presents 
few  if  any  pustules.  The  hair  in  sycosis  is  only 
affected  secondarily,  and  is  firmly  planted  in  the  skin, 
giving  rise  to  pahi  on  extraction.  In  trichophytosis 
barbae  it  is  primarily  affected,  split,  twisted,  broken, 
and  is  readily  extracted  without  pain.  In  sycosis  there 
is  no  fungus;  in  trichophytosis  it  is  often  abundantly 
present.  Sycosis  relapses  when  apparently  cured,  and 
often  seems  to  get  better  and  worse  with  the  condition 
of  the  patient's  health.  Trichophytosis  barbae  is  not 
so  prone  to  relapse,  and  is  not  influenced  by  the  condi- 
tion of  the  patient's  health. 

Eczema  barbce  is  an  active  inflammation  of  the  skin 
of  the  bearded  portion  of  the  face;  tinea  barbce  is  an 
inflammation  of  the  hair-folhcles.  Eczema  develops 
rapidly;  involves  large  portions  of  the  bearded  face, 
or  aU  of  it;  is  devoid  of  nodular  swelhngs;  and  pre- 
sents a  large  amount  of  crusting.  Tinea  barbae  is 
gradual  in  its  advance,  affects  the  chin  and  submaxil- 
lary regions,  spares  the  skin  between  the  tubercles, 
nodules,  and  groups  of  the  same,  and,  as  a  rule,  is  not 
crusted.      In  eczema  the  hairs  are  firmly  fixed  and 


TRICHOPHYTOSIS    BARB^.  251 

free  of  disease;  in  tinea  barbae  they  are  evidently 
diseased,  easily  extracted,  and  often  wanting.  Eczema 
is  accompanied  with  far  more  itching  and  burning 
than  is  tinea  barba3,  and  is  not  contagious. 

The  large  papular  or  tubercular  sypliilides  tend  to 
group  in  circles  or  segments  of  circles,  as  do  the  lesions 
of  trichophytosis  barbae.  Bub  there  is  generally  no 
more  than  one  group  of  lesions  in  syphilis;  it  has  a 
characteristic  color,  and  a  different  history;  other  evi- 
dence of  syphihs  may  be  found,  and  the  lesions  tend 
to  ulcerate. 

Acne  indurata  occurs  not  only  on  the  hairy  but  also 
on  the  non- hairy  parts  of  the  face;  does  not  involve 
the  hair;  and  if  the  nodules,  which  here  are  cutaneous 
abscesses,  are  opened,  they  give  vent  to  a  large  amount 
of  pm"ulent  sebaceous  matter.     A  parasite  is  wanting. 

Epithelioma  should  hardly  be  mistaken  for  tricho- 
phytosis barbae.  It  occurs  in  the  form  of  a  circuni 
scribed  lesion  with  waxy  margins  over  which  course 
fine  blood-vessels.  The  whole  history  of  its  origin 
and  progress  is  different  from  what  pertains  to  tinea 
barbae,  and  when  the  almost  inevitable  ulceration  takes 
place  all  doubt  as  to  its  nature  vanishes. 

The  superficial  form  of  tinea  harhce  presents  the 
same  appearances  and  has  the  same  symptoms  as  met 
with  in  tinea  corporis,  viz. :  a  superficial,  more  or  less 
circular  scaly  patch,  with  a  vesicular  or  pustular  ad- 
vancing edge. 

Treatment. — The  treatment  of  trichophytosis  barbae 
is  prophylactic  and  curative.  Prophylaxis  consists  in 
not  being  shaved  by  a  barber,  or,  better,  in  not  shav- 
ing at  all,  as  the  disease  rarely  affects  those  who  do  not 
shave.  If  you  go  to  a  barber's  shop,  owning  your 
own  brush,  cup,  and  razor  will  not  save  you.  You  do 
not  know  that  you  can  always  trust  your  barber  not 
to  use  your  apparatus  on  other  men's  faces.     Then 


25^  DISEASES   OF  THE   HAIR  AND  SCALP. 

too,  as  has  been  said,  the  damp  towels,  the  razor  strop, 
and  perhaps  the  barber's  fingers,  may  convey  the  con- 
tagion. If  you  do  not  own  your  ot\ti  utensils,  of 
course,  your  chances  are  all  the  worse.  Above  all 
things,  the  cheaper  class  of  barber's  shops  are  to  be 
avoided. 

The  curative  treatment  follows  very  much  the  same 
line  as  given  in  the  two  preceding  chapters.  In  the 
early  stage,  and  before  the  hair-foUicles  have  become 
involved,  we  can  often  succeed  in  stopping  the  pro- 
gi-ess  of  the  disease  by  painting  the  affected  part  with 
a  solution  of  four  or  five  grains  of  the  bichloride  of 
mercury  to  the  ounce  of  alcohol,  to  whicli  may  be 
added  a  little  glycerine.  This  is  to  be  painted  on 
twice  a  day  with  a  cotton  swab,  a  fresh  one  being  used 
for  each  application.  Ihle  (515)  extols  resorcin  for 
this  stage,  exhibited  in  the  following  paste: 

Pure  resorcin,  ....         10. 

White  vasehne,        ....        50. 
Oxide  of  zinc. 

Starch, aa     25. 

M 

Apply  two  or  three  times  a  day. 

Painting  with  the  tincture  of  iodine;  the  apphcation 
of  a  chrysarobin  pigment,  (Chrysarobin  10  per  cent,  in 
flexible  coUodion);  the  various  mercurial  ointments,  are 
all  good  at  this  stage.  When  the  hair-foUicles  have 
been  invaded,  and  tubercles  formed,  a  more  active 
treatment  must  be  instituted.  Epilation  now  forms 
an  essential  part  of  the  treatment.  The  hair  is  to  be 
puUed  not  only  from  over  the  lesions  but  also  for  a 
smaU  zone  about  them.  Shaving  is  also  to  be  prac- 
tised, and  it  is  often  well  to  shave  one  day  and  epilate 
the  second  or  third  day,  according  to  the  rapidity  with 
which  the  hair  grows.     Ihle  claims  that  by  using  his 


TRICHOPHYTOSIS    BARB^.  2^3 

paste,  as  given  above,  epilation  is  not  necessary,  as 
the  diseased  hairs  come  out  of  themselves.  He  advises 
cutting  of  the  beard  and  applying  the  paste  two  or 
three  times  a  day,  its  strength  being  gradually  in- 
creased if  well  borne,  up  to  twenty -five  or  fifty  per 
cent.  When  pustulation  and  inflammation  begin  to 
lessen,  the  strength  of  the  resorcin  is  to  be  reduced. 
When  apparently  well,  a  three  per  cent,  ointment  is 
to  be  continued  for  some  time. 

The  rule,  however,  is  to  epilate  and  shave,  and  to 
apply  your  parasiticide  after  either,  and  re -apply  it  two 
or  three  times  a  day.  A  bichloride  of  mercury  solu- 
tion, gr.  i  to  ij,  in  water  or  alcohol  3  j;  a  solution  of 
hyposulphite  of  soda  3  j,  to  water  3  3 ;  dilute  sulphurous 
acid;  a  two  to  four  per  cent,  carbolized  oil;  a  five  to 
ten  per  cent  salicylated  oil  (castor  oil  preferred);  a  five 
to  ten  per  cent,  oleate  of  mercury;  a  saturated  solution 
of  boracic  acid;  tincture  of  iodine;  an  ointment  of 
sulphur,  or  of  yellow  sulphate  of  mercury,  thymol, 
or  napthol;  these  are  all  good  parasitics.  Tilbury  Fox 
(512)  advised  the  use  of  an  ointment  composed  of 

Hydrarg.  Ammoniate. 
Hydrarg.  oxidat.  nitrici, 
Acidi  carbohci, 
M    Adepis, 

Hardy  (514)  directs  that  the  part  be  epilated  and 
then  bathed  with  a  sublimate  solution  1  in  500.  The 
next  day  an  ointment  composed  of 


gr.v 

= 

.3 

gr.Y 

= 

.3 

gr.x 

= 

.6 

!] 

= 

30. 

Hydrarg.  sulph.  flavae,    . 

2  parts 

Pulv.  camphoris, 

1  part. 

M 

Adepis, 

27  parts 

or  of 

Sulphur,  subhmat. 

2  parts 

M 

Adepis, 

.       28      '' 

254  DISEASES   OF  THE  HAIR  AND  SCALP. 

is  to  be  constantly  worn.  When  there  is  much  in- 
flammation he  uses  emollient  dressings  until  it  has 
subsided,  and  then  employs  the  above  plan.  Neumann 
(27)  advises  green  soap  frictions,  the  opening  of  pus- 
tules and  multiple  scarifications  of  the  patches.  When 
there  is  deep  infiltration  he  uses  a  plaster  composed 
of  equal  parts  of  mercurial  and  diachylon  plaster,  with 
enough  olive  oil  to  make  it  soft. 

Behrend  (3)  speaks  highly  of  scraping  the  patch  or 
patches  with  the  sharp  spoon.  Gamberini  (59)  paints  the 
affected  parts  with  a  solution  of  oil  of  juniper  in  tinct- 
ure of  iodine.  Li  the  Algemein.  Wien.  Med.  Zeit. 
(506)  for  1881,  it  is  recommended  to  apply  after  epila- 
tion and  every  morning  and  evening,  the  following: 

Hydrarg.  bichlor 01.-02 

Sapo-viridis, 
M    01.  cade,  .        .        .        aa   5. 

Epilating,  shaving,  and  the  careful  use  of  parasiticides 
will  effect  a  cure. 

Morrow  ^  epilates  and  applies  an  ointment  of  iodide 
of  sulphur,  thirty  or  forty  grains  to  the  ounce.  Unna 
in  superficial  cases  recommends  a  ten-per-cent.  resor- 
cin  ointment,  or  a  spray  of 

5  Eesorcin,  .        .        .  .5. 

Hydrarg.  bichlor.,  .        .  .         .01-05 

Aquae  Colognien., 

Alcohol,  ....  50. 

01.  ricini,         .        .        .  .       1. 
M. 

followed  by  powdering.  In  the  nodular  form  he  binds 
on  plaster-mulls  made  either  of  hydrarg.  20,  ac. 
carbol.  7.5;  or  hydrarg.   10,  ac.  carbol.   10,  corrosive 

*  Journal  of  Cutaneous  and  Venereal  Diseases,  1886,  iv.,  32. 


TRICHOPHYTOSIS  BARB.^..  255 

sublimate  1 ;  or  the  last  with  two  parts  of  sublimate 
and  ten  of  oxide  of  zinc. 

Prognosis.  —When  left  to  itself  the  disease  is  very 
chronic.  It  may  end  spontaneously,  though  with  per- 
manent loss  of  hair.  If  properly  treated  it  is  perfectly 
curable,  and  leaves  no  traces.  The  prognosis  of  ring- 
worm of  the  beard  is  indeed  the  same  as  that  of  the 
head,  though  it  is  somewhat  easier  to  cure. 


CHAPTER  XY. 

FA^TS. 

Derivation:    Favus  (Lat.)  a  honeycomb. 

Synonyms. — Porrigo  lupinosa  OVillax;)  Porrigo 
favosa,  Porrigo  lavalis;  Porrigo  scutalata  (Lebert); 
Porrigophyta  (Gruby);  Tinea  favosa;  Tinea  vera; 
Tinea  ficosa  (Pare);  Tinea  lupinosa  (Gui  de  Chaliac; 
Tinea  maligna;  Trichomykosis  favosa  (Auspitz);  Der- 
matomycosis  favosa;  Kerion;  Teigne  faveuse  (Ali- 
bert);  Teigne  clu  pauvre;  Crusted  or  honeycomb 
ringworm,  scall  head,  true  porrigo  (Eng.);  Erbgrind 
(Ger.);  Kopskurv.  (Slav). 

Definition. —  A  contagious  vegetable  parasitic  dis- 
ease due  to  the  invasion  of  the  hairy  scalp  by  the 
Acliorion  Schoenleinii.  It  is  characterised  by  the  pres- 
ence of  discrete  or  confluent,  circular,  pale,  sulphur- 
yellow  cupped  crusts  perforated  by  hair,  or  by  asbestos- 
Hke  masses  of  gi-ayish  ciiists;  by  loss  of  hair  producing 
irregularly  shaped,  disseminated,  red  bald  patches;  by 
running  a  chronic  course;  and  by  causing  permanent 
atrophy  of  the  scalp. 

Symptoms.— Favus  begins  either  as  one  or  more 
scaly  erythematous  spots,  as  minute  yellowish  pmicta 
or  as  a  group  of  vesicles  smaller  than  those  met  with 
in  lingworm.  But  though  this  is  the  mode  of  origin, 
the  physician  seldom  sees  a  case  in  that  stage,  except- 
ing as  he  may  find  new  points  developing  upon  a  scalp 
akeady  bearing  the  disease  in  a  pronounced  form. 
As  usually  met  with,  we  find  that  the  hair  is  dry  and 
lustreless,  and  in  places  it  has  fallen  out,  leaving  irregu- 
larly shaped  bald  patches,  of  all  sizes,  and  of  rather 
brilliant  red  color.      Upon  separating  the  hairs,  and 


]PAVUS.  257 

examining  the  scalp  more  closely,  we  will  find  both 
upon  the  bald  patches  and  upon  parts  of  the  scalp 
covered  with  hair,  Uttle,  sulphur-yellow,  cup  or  saucer- 
shaped  crusts,  with  raised  or  rounded  edges,  out  of  the 
middle  of  which  one  or  several  hairs  will  be  growing. 
Besides  these  cups  there  will  be  more  or  less  scaling, 
and  if  the  disease  is  of  some  age,  thick,  mortar-like 


Favus. 


crusts  of  grayish  color.  If  we  approach  near  enough 
to  the  patient,  we  will  appreciate  a  peculiar  odor  from 
the  scalp. 

The  characteristic  features  of  favus  are:  1.  Sulphur- 
yellow  cupped  crusts.  2.  Baldness  occurring  in  irregu- 
lar patches.  3.  Dryness  and  loss  of  lustre  of  the  hair. 
4.  A  peculiar  odor.  In  a  typical  case  all  these  symp- 
toms are  present.     Let  us  examine  each  one  by  itself. 

1.  The  cupped  cnists.  These  are  present  very 
shortly  after  the  commencement  of  the  disease,  and 


258  DISEASES  OF  THE   HAIR  AND   SCALP. 

are  to  be  found  at  some  period  in  all  cases.  They  are 
situated  about  the  hair-foUicles.  At  their  beginning 
tliey  are  small,  about  the  size  of  a  pin  head,  but  grow- 
ing rapidly  they  attain  the  size  of  a  split  pea.  These 
are  called  favi  or  scutula.  Though  usually  described 
as  cup-shaped,  they  seem  to  me  to  be  more  like  a  sau- 
cer in  form.  Their  edges  are  rounded  and  several 
lines  in  thickness.  The  depression  in  their  centres  is 
well  marked.  They  are  round  and  concavo-convex, 
the  concavity  looking  upwards.  At  first  they  are 
covered  with  a  thin  layer  of  epidermis,  but  later  the 
edges  are  free.  When  they  are  picked  off  fi'om  the 
scalp,  which  can  readily  be  done,  they  leave  a  moist 
depression,  which  soon  fills  up.  Or  the  scalp,  under 
them,  may  be  dry,  red  and  atrophied;  or  it  may  be 
pustular.  The  color  of  the  crust  is  pale  or  sulphur 
yellow:  if  of  long  standing  it  may  become  a  dirty  or 
greenish  yellow  from  extraneous  matter.  The  surface 
of  the  crust  is  uneven,  and  its  centre  is  pierced  by  one 
or  more  hairs.  These  crusts  occur  discretely  and  dis- 
seminated ;  sometimes  in  groups.  They  are  firm  in 
consistence,  and  when  crushed  between  the  fingers 
they  impart  a  feeling  of  crumbling,  somewhat  Uke 
mortar.     Around  them  is  a  slight  zone  of  redness. 

In  old  cases  these  cupped  crusts  may  not  be  present. 
We  will  then  find  thick  mortar  or  asbestos -like  grayish 
crumbly  masses  of  scales,  or  perhaps  these  may  be 
gi'eenish  yellow  as  if  they  were  composed  of  dried  pus. 
But  if  they  are  cleared  off  and  the  scalp  left  to  itself, 
the  scutula  will  again  develop. 

2.  Baldness  occurring  in  irregular  patches.  This  is 
almost  as  characteristic  of  fa^ois  as  are  the  scutula. 
The  patches  are  of  all  shapes,  though  they  show  little 
inclination  to  become  round  or  oval.  There  may  be 
only  one  or  two  bald  spots,  or  the  whole  scalp  may  be 
so  denuded  of  hair  that  the  condition  may  be  better  de- 


FAVUS.  259 

scribed  as  a  bald  scalp  with  irregularly  shaped  and  sized 
patches  of  hair.  In  the  active  stage  of  the  disease  the 
bald  patches  are  covered  more  or  less  with  scutula  and 
crusts,  and  here  and  there  will  be  solitary  hairs,  or 
little  tufts  of  hair.  Their  color  is  an  inflammatory 
red  in  the  active  stage,  v/hich  pales  with  time.  They 
have  a  cicatricial  look,  due  to  the  atrophy  which 
always  takes  place.  They  are  wanting  in  glands  and 
hair -follicles,  and  are  permanent. 

3.  Dryness  and  loss  of  lustre  of  the  hair  are  always 
present.  The  hair,  unlike  what  obtains  in  lingworm, 
is  affected  secondarily,  and  grows,  though  with  impaired 
vigor,  for  some  time  after  the  scutula  have  formed. 
Eventually,  the  growth  of  the  hair  is  interfered  with 
by  the  general  atrophy  of  the  skin,  and  by  invasion  of 
their  roots  and  shafts  by  the  parasite.  They  then  be- 
come dry  and  brittle  and,  may  be,  split  longitudinally 
and  fall  out  of  themselves,  or  on  account  of  traction 
from  brushing,  scratching,  and  the  like.  They  are 
easily  pulled  out  when  their  roots  are  invaded  and  do 
not  break  so  readily  as  in  ringworm. 

4.  The  odor  is  always  present  in  a  well-marked  un- 
treated case,  and  has  been  variously  described  as 
"  menagerie  like,"  or  "  mousey  "  or,  like  the  urine  of 
cats,  or  as  "stale  straw."  In  doubtful  cases  it  may 
be  an  aid  in  diagnosis  as  it  is  quite  unlike  the  smell  of 
pustular  eczema  or  syphilis. 

Itching  is  the  only  subjective  symptom.  Tlie  disease 
may  be  complicated  by  eczema,  syphilis,  pediculosis, 
or  any  other  disease  of  the  scalp,  and  these  may  some- 
what alter  the  chnical  appearances.  In  this  way  we 
may  have  a  decidedly  pustular  element  added.  In 
Eandall's  Island  Hospitals  there  are  always  some  forty 
or  more  ringworm  and  favus  cases  in  the  same  wards. 
During  four  years  I  have  never  seen  a  case  of  ring- 
worm and  favus  on  the  sair.':  scalp, though  the  children 


260  DISEASES   OF   THE   HAIR  AND   SCALP. 

mingle  freely  with  each  other.  As  in  other  inflamma- 
tory diseases  of  the  scalp,  enlargement  of  the  glands 
of  the  neck  are  quite  commonly  encountered.  Kaposi 
(19)  says,  that  in  the  course  of  such  fevers  as  typhus, 
variola,  and  pneumonia,  the  favus  growth  is  checked 
only  to  begin  again  in  convalescence. 

Various  names  have  been  aj^plied  to  designate  the 
different  chnical  pictures  presented  by  favus.  Thus 
we  have:  F.  discretus,  when  confined  to  one  spot;  F. 
confertus,  when  it  extends  over  large  surfaces;  F. 
scutiformis,  when  in  moderate  oval  patches;  F.  cohoer- 
ens,  when  a  number  of  cups  join;  F.  gran ulatus,  when 
in  mortar  hke  masses;  F.  urceolaris  or  dispersus,  when 
disseminated.  Charpy  (539)  has  described  one  form 
in  which  the  crusts  are  millet  seed  sized  and  dissemi- 
nated throughout  the  hair,  to  wliich  he  has  given  the 
name  of  F.  miliaire. 

Etiology. — The  disease  is  due  to  the  implantation 
and  growth  of  the  acliorion  Schomleinii  primarily  in 
the  scalp  and  secondarily  in  the  hair.  This  vegetable 
fungus  was  first  described  by  Schoxlein  in  1839,  in 
Mueller's  Archiv  filr  Anatomie  unci  Physiologie.  In 
181:1,  Gruby  also  described  it,  and  at  the  time  he  was 
unaware  of  the  discovery  of  Schonlein. 

Favus  is  highly  contagious,  though  not  so  much  so 
as  is  ringworm.  Its  victims  are  mostly  children  of 
the  poorer  classes,  such  as  Hungarians,  Poles,  and 
other  foreigners,  who  neglect  the  most  ordinary  rules 
of  h3^giene.  It  is  exceedingly  rare  to  see  favus  of  the 
scalp  in  our  own  people,  and  in  this  country  it  is  one 
of  the  rarer  skin  diseases;  the  statistics  of  the  Ameri- 
can Dermatological  Association  in  1885  record  only  32 
cases  in  16,863.  But  while  it  is  not  so  contagious  as 
is  ringworm,  it  is  more  persistent.      While  ringworm 


FAVUS.  261 

tends  to  spontaneous  recovery  as  puberty  is  reached, 
and  it  is  exceedingly  uncommon  to  see  it  in  the  adult, 
favus  persists  indefioitely.  I  have  seem  it  in  a  woman 
well  on  in  her  twenties,  and  in  a  man  in  his  thirties, 
not  only  in  the  form  of  permanent  bald  spots,  but  with 
scutula  and  asbestos  crusts.  The  disease  may  be  ac- 
quired either  mediately  or  immediately;  that  is,  directly 
from  another  individual  suffering  with  the  disease,  or 
by  wearing  the  cap  or  using  the  brush  or  comb  of  a 
favus  patient.  Hebra  and  Kaposi  (15)  say  it  is  more 
common  in  males  than  females.  Bergeron  (45)  found 
that  it  was  more  prevalent  in  the  country  than  in  the 
city.  It  does  not  affect  all  individuals,  but  seems  to 
require  some  undefined  peculiarity  of  soil  for  its  lodge- 
ment and  growth.  How  great  a  role  the  strumous  or 
other  diathesis  plays  in  etiology  it  is  difficult  to  deter- 
mine. Many  of  the  children  with  favus  are  strumous, 
but  that  is  a  very  common  condition  in  this  class  of 
children.  Aubert  (533)  asserts  that  the  disease  is 
prone  to  follow  injuries  to  the  scalp,  and  Kaposi  (19) 
says  that  the  spores  must  land  upon  macerated  epider- 
mis or  in  a  hair-follicle,  and  lie  there  for  some  little 
time  before  they  wiU  grow. 

Animals  are  subject  to  favus,  and  from  them  it  may 
be  acquired  by  mam  It  occurs  in  mice,  rabbits,  dogs, 
fowls  and  cats.  When  occurring  in  the  mouse  the 
pressure  of  the  fungus  may  cause  not  only  atrophy  of 
the  skin  but  also  of  the  bones  of  the  skull,  and  kill  the 
animal  by  exposure  of  the  brain,  the  bones  of  the  skull 
being  completely  destroyed. 

Pathology. — A.R.  Eobinson  (33),  who  has  carefully 
investigated  the  parasitic  diseases  of  the  skin,  thus 
describes  the  appearances  of  favus:  ^'  The  mass  (favus 
cup)  is  composed  almost  wholly  of  the  luxuriant  vege- 
table growth  in  various  stages  of  development.  The 
most  apparent  is  the  mycelium  in  the  shape  of  flat, 


202  DISEASES   OF  THE   HAIR   AXD   SCALP. 

narrow  threads  branching  and  inosculating  with  one 
another  in  various  directions .  Their  diameter  is  about 
the  -glo-  part  of  an  inch,  and  their  color  is  pale-gray, 


Favus  ^Kaposi.) 

sometimes  tinged  with  green.  When  in  a  state  of 
fructification  these  tubes  ajt^e  divided  into  numerous 
smaR  compartments  by  delicate  cross  lines,  sometimes 


FAVUS.  263 

with  constrictions,  giving  a  chain-like  appearance; 
and  in  each  compartment  are  seen  young  spores  in 
various  stages  of  grow^th.  The  spores  or  conidia  are 
present  in  abundance  amid  the  meshes  of  the  ai)parent 
growth.  They  are  very  small,  of  varying  form,  round, 
oval,  flask  or  dumb-bell  shaped,  and  of  a  pale  greenis]) 
color.  Intermediate  forms  between  the  spores  and 
mycelia  are  always  present,  and  fungoid  grow^ths  of 
various  kinds,  as  well  as  micrococci  and  bacteria,  are 
often  accidentally  in  the  field  of  view. 

''  The  parasite  first  obtains  a  lodgement  in  the  fun- 
nel-shaped depression  in  the  epidermis,  through  wdiich 
the  hair-shaft  emerges  upon  the  surface.  It  grows 
luxuriantly  in  the  upper  part  of  the  hair-sac,  and  in- 
sinuates itself  on  all  sides  between  the  superficial  layers 
of  the  epidermis.  When  it  reaches  a  short  distance 
on  all  sides  of  the  foUicle-mouth,  it  breaks  the  looser 
layers  and  appears  on  the  surface,  giving  us  the 
familiar  cup-shaped  bodies.  It  also  invades  the  hair- 
shaft  itself,  though  not  to  the  extent  that  the  tricho- 
phyton does.  It  penetrates  between  the  cellular  layers 
of  the  root  sheath,  and  multiplies  in  the  cortical  sub- 
stance of  the  hair.  The  nutrition  of  the  hair  is  inter- 
fered with  by  the  mechanical  pressure  of  the  growth 
upon  the  papiUse.  The  hair  falls  out,  and  eventually, 
in  many  cases,  the  papilla  atrophies,  and  a  new  growth 
becomes  impossible.  In  cases  of  any  standing  the 
parasite  may  be  demonstrated  not  only  in  the  cortical, 
but  in  the  medullary  substance  of  the  hair.  Splitting 
of  the  hair  may  occur,  as  in  tinea  tonsurans,  but  as  a 
usual  thing  the  hair  faUs  out  before  that  occurs. 

^'  In  the  skin  itself  the  pai*asite  usually  confines  itself 
to  the  upper  corneous  cells,  and  does  not  extend  to  the 
living  tissues.  In  cases  where  the  surface  is  covered 
by  irregular,  moi^tar-like  masses  of  parasite,  the  entire 


204:  DISEASES   OF   THE   HAIK   AND   SCALP. 

upper  layer  of  the  epidermis  will  be  foujid  infiltrated 
with  the  achorion. 

' '  The  coriuni  itself  is  usually  in  a  state  of  chronic 
inflammation,  and  suppuration,  which  may  be  quite 
abundant,  often  occurs  under  the  crusts.  Even  where 
no  pus  is  found,  the  pressure  of  the  parasite  causes 
atrophy  of  the  skin,  and  at  last  pit -like  depressions,  or 
more  extensive  reddened  scars  are  left.  When  the 
granular  stiiictures  are  entirely  destroyed,  the  achorion 
no  longer  finds  a  suitable  nidus,  and  the  disease  at 
that  spot  is  at  an  end." 

The  fungus  of  favus  does  not  aftect  the  hairs  so 
readily  as  does  that  of  ringworm.  Unna  (^57*J)  has 
found  that  the  hair  is  sometimes  diseased  only  in  its 
upper  one-third,  while  the  inner  root -sheath  is  diseased 
throughout.  Sometimes,  on  the  other  hand,  the  hair 
may  be  diseased  throughout  and  the  inner  root-sheath 
unaft'ected.  He  has  found  the  hau'-bulb  uniformly  free 
from  fungus,  and  the  cortex  generally  undiseased  till 
to  about  the  upper  border  of  the  lower  fourth  of  the 
hair-foUicle.  The  usual  point  of  entrance  of  the  fmi- 
gus  into  the  hair  is  at  that  part  of  the  hair  foUicle 
where  the  sebaceous  glands  find  entrance,  the  fungus 
making  its  way  through  the  cuticle  of  the  hair.  From 
the  point  of  the  entrance  into  the  hair,  the  fungus 
grows  up  and  down.  The  achorion  furnishes  a  cement 
to  the  corneous  cells  in  which  it  lives,  so  that  the  cor- 
neous layers  do  not  scale  off  but  form  cups,  and,  later, 
mouldy  or  Ijrittle  masses,  and  the  hairs  do  not  break 
up  as  in  trichophytosis. 

The  formation  of  the  yellow  cup  is  accounted  for  in 
several  ways.  1.  The  parasite  gains  entrance  into  the 
hair-follicle  and  grows  out  in  all  directions  from  it  as 
a  centre.  The  outer  rings  are  the  newest  and  more 
succulent,  while  those  nearer  the  hair  or  point  of  de- 
parture are  the  oldest  and  drier.      Hence  the  latter 


FAVUS.  265 

will  be  depressed  by  the  pressure  of  the  atmosphere. 
2.  The  epidermic  cells  in  the  immediate  neighborhood 
of  the  hair  are  more  firmly  attached  to  the  hair  than 
are  those  further  away,  hence  will  not  so  readily  give 
way  and  bow  out  under  the  pressure  of  the  parasitic 
growth.  3.  EoBiNSON  (33)  has  shown  that  the  peripheral 
portion  of  the  cup  consists  of  a  dense  collection  of  my- 
celia,  imbedded  in  a  granular  debris,  while  the  central 
lX)rtion  is  composed  ahiiost  entirely  of  spores  which  are 
not  very  closely  packed  together.  From  this  it  results 
that  the  peripheral  portion  of  the  cup  is  much  firmer 
and  more  resistant  to  external  pressure  than  the  cen- 
tral part,  and  does  not  so  readily  sink  in. 

The  objective  symptoms  of  favus  are  due  to  the 
growth  of  the  achorion.  The  skin  is  atrophied  on 
account  of  the  pressm^e  of  the  growing  fungus  upon 
the  constituents  of  the  skin,  squeezing,  as  it  were,  the 
life  out  of  them.  Whether  the  achorion  Schoenleinii 
is  the  only  parasite  causing  favus  is  a  question  that  is 
still  under  discussion.  The  majority  of  investigators 
believe  that  it  is,  and  inoculation  experiments  support 
them  in  their  belief.  Grawitz  (435)  has  recently  in- 
oculated several  subjects  with  pure  cultures  of  favus 
and  ringworm,  and  each  has  produced  the  disease  pe- 
culiar to  itself  alone.  Quincke  (508)  has  found  in  his 
cultures  of  favus  crusts,  that  at  least  three  different 
fungi  are  capable  of  producing  the  clinical  picture  of 
favus.  In  each  of  the  examined  cases,  one  form  was 
found.  The  three  forms  he  designates  only  as  ^,  fi,  y 
fungi.  They  show  marked  difference  under  cultivation. 
As  yet  Quincke  has  not  been  able  to  classify  them 
botanically.  Unna  (402  ap.)  has  outdone  Quincke  and 
describes  no  less  than  nine  sorts  of  favus  fungus.  On 
the  other  hand.  Pick,  supported  by  Kral  (382,  383  ap.), 
and  MiBELLi  have  found  only  one  fungus.  At  present 
the  question  is  far  from  settled,  and  it  is  not  possible 


266  DISEASES   OF   THE   HAIR   AND   SCALP. 

to  give  here  the  details  of  the  investigations  of  the 
bacteriologists.  It  is  probable  that  the  so-called 
'^forms'' are  due  to  the  different  methods  of  the  ob- 
servers in  making  cultures,  and  to  the  different  reac- 
tions of  different  skins  to  the  favus  irritation. 

Diagnosis. — Most  cases  of  favus  are  easy  of  diag- 
nosis, tlieir  features  of  sulphur-yellow  cupped  crusts  ; 
asbestos-like  grayish  masses  ;  red,  atrophic  bald  spots; 
and  peculiar  odor,  being  so  well  marked.  It  is  to  be 
differentiated  from  ringworm,  eczema,  seborrhoea 
sicca,  psoriasis,  lupus  erythematosus,  and  baldness 
arising  from  various  other  causes. 

1.  From  Ringworm.  Ringworm  is  met  T\'ith  chiefly 
in  children,  rarely  persisting  to  the  age  of  puberty. 
Favus  usually  begins  in  early  hfe,  but  often  continues 
into  the  period  of  adult  life.  Ringworm  is  indigenous; 
fa^iis  is  most  often  an  hnpoited  disease,  and  is  met 
vdi\\  in  Hungarians,  Poles,  and  other  foreign  races 
which  are  uncleanly  in  their  habits.  Ringworm  occurs 
in  the  form  of  ch'cular,  ch'cumscribed  spots,  partially 
denuded  of  hau-,  and  covered  with  grayish  scales  in 
moderate  amount.  It  has  no  cupped  crusts,  and  entire 
baldness  is  rare  except  from  the  results  of  treatment. 
Favus  is  more  multiform  and  presents  to  view  either 
discrete  or  grouped  yellow-cupped  cnists;  or  gray 
mortar -like  masses  of  parasitic  debris;  or  UTegularly 
shaped  bald  spots  scattered  througli  the  whole  head, 
wdiich  are  atrophic,  devoid  of  follicles,  and  either  red 
or  white  in  color,  according  to  then-  age.  In  some 
cases  there  wiU  be  a  mixtm-e  of  all  these  features.  In 
ringworm  the  hau's  look  as  if  nibbled  off,  and  we  find 
many  ^'stumps;"  in  fa^Tis  stumps  are  not  met  with, 
and  the  ban*  though  dry  and  cracked  is  not  broken  off. 
^lien  we  attempt  to  epilate  m  ring-worm  the  hair 
breaks  and  leaves  its  root  behind;  in  fa^-us  the  hair 
^Wth  its  root  wiU  come  out  entire.     Ring*Avorm  has 


FAVUS.  267 

no  characteristic  odor.  In  a  well-marked  case  of 
favus  the  odor  of  stale  straw  or  mice  will  be  readily 
appreciated.  In  doubtful  cases  we  may  often  decide 
whether  the  disease  is  ringworm  or  favus  by  the 
microscope.  The  conidia  of  favus  are  more  mani- 
fold in  shape  than  those  of  ringworm  and  slightly 
larger.  In  the  hair,  in  favus,  we  have  chiefly  my- 
celia,  which  sometimes  are  exceedingly  long;  while 
in  ringworm  the  conidia  are  found  in  greater  abun- 
dance. But  it  is  by  no  means  easy  to  accurately  differ- 
entiate between  the  two  diseases  by  the  microscope 
alone,  and  we  must  trust  chiefly  to  the  symptoms 
and  course  of  the  disease  in  our  diagnosis. 

2.  From  eczema  favus  needs  to  be  differentiated  when 
it  is  of  long  standing  and  there  are  no  cupped  crusts  pres- 
ent. Sometimes  the  scalp  of  a  patient  with  favus  may  be 
irritated  by  treatment  to  such  an  extent  that  it  may 
become  eczematous ;  but  this  is  an  accident  that  need  not 
detain  us.  We  would  speak  here  of  the  diagnosis  from 
pustular  eczema  in  a  doubtful  case.  In  favus  we 
have  often  a  history  of  contagion,  which  is  not  found 
in  eczema.  Favus  is  usually  confined  to  the  hairy  scalp. 
Eczema  of  the  scalp  is  usually  accompanied  by  eczema 
behind  the  ears,  and  quite  commonly  it  extends  upon 
the  neck  and  forehead.  The  grayish,  dirty-looking, 
thick,  friable  crusts  of  favus  are  in  strong  contrast 
with  the  greenish,  tenacious  crusts  of  eczema.  On 
removing  a  favic  crust  we  leave  a  dry,  red  surface. 
When  an  eczematous  crust  is  removed,  a  moist,  ex- 
uding surface  is  exposed.  In  favus  the  hair  is  dry, 
lustreless,  and  more  or  less  spHt  longitudinally.  In 
eczema  the  hair  is  matted  together,  and  may  be  dry, 
but  it  is  not  otherwise  altered.  Favus  causes  perma- 
nent bald  spots  of  red  and  atrophic  appearance.  Ec- 
zema as  a  rule  does  not  cause  baldness,  and  never 
gives  rise  to  permanent  alopecia.      The  mousey  odor 


268  DISEASES  OF  THE  HAIR  AND  SCALP. 

of  favus  is  vastl}^  different  from  the  sickening  smell  of 
pustular  eczema. 

The  pustules  of  a  discrete  pustular  eczema  or  im- 
petigo are  rounded,  non-umbiUcated,  whitish  or  grayish 
in  color,  and  contain  pus.  These  should  not  be  con- 
founded with  the  straw-colored  or  yellow  cups  of  favus, 
which  are  umbilicated  and  firm  and  do  not  contain 
pus. 

3.  From  seborrhcea  sicca.  Favus  affects  all  parts  of 
the  scalp  indifferently  and  irregularly;  seborrhcea  is 
most  frequently  confined  to  the  upper  portions  of  the 
head,  and  when  present  to  a  sufficient  degree  to  require 
differentiation  from  favus,  it  will  form  a  continuous 
patch  covering  the  whole  top  of  the  head  with  the  hair 
dry  and  more  or  less  matted.  The  crust  of  favus  is  diy 
and  brittle  and  gritty  to  the  feel:  that  of  seborrhcea 
is  friable,  but  greasy  to  the  feel,  and  when  removed 
leaves  a  normal  or  pale  skin.  Seborrhcea  has  no  char- 
acteristic odor,  no  cups,  and  if  it  causes  baldness  it 
will  be  at  first  a  general  thimiing  of  the  hair,  and 
with  it  the  amount  of  seborrhcea  will  lessen.  The  bald- 
ness caused  by  favus  is  permanent,  and  the  skin  is 
smooth  and  atrophic. 

4.  From  Psoriasis.  Psoriasis  does  not  occur  upon 
the  scalp  alone;  when  found  there,  other  lesions  will 
be  found  elsewhere  on  the  body.  Favus  is  quite  gen- 
erally found  on  the  scalp  alone.  The  crusts  of  psoriasis 
are  scattered  about  through  the  whole  scalp,  are  cir- 
cumscribed and  discrete,  and  when  removed  the  skin 
underneath  will  be  found  reddened  but  not  ati'ophic. 
Psoriasis  presents  no  lesion  like  the  cupped  ciTist  of 
favus,  and  does  not  cause  permanent  baldness. 

5.  Ltqnis  erythematosus  resembles  favus  only  in 
forming  red  cicatricial  bald  areas,  wliich  are  crusted. 
Its  bald  patches  are  really  cicatricial,  while  those  of 
favus  are  atrophic.     The  cicatrix  of  lupus  is  often  de- 


FAVUS.  269 

forming.  Lupus  is  much  slower  than  fa\ais  in  its 
course,  is  generally  more  limited  in  its  distribution,  has 
no  cupped  crusts,  and  when  crusted  the  crust  is  thin 
and  adherent,  and  never  forms  the  thick  mortar-like 
masses  of  favus. 

6.  From  Alopecia.  Alopecia  areata  presents  per- 
fectly bald,  smooth,  non- scaly,  white,  circular,  cir- 
cumscribed patches,  the  skin  of  which  is  normal  in 
appearance,  though  it  may  be  somewhat  pale  and  thin. 
Its  history  and  course  are  distinct  from  what  obtains 
in  favus.  The  baldness  arising  from  syphilis,  as 
seen  in  the  early  stages  of  the  disease,  and  due  to  the 
general  hydraemia,  is  more  like  the  baldness  arising 
from  favus  than  is  any  other  form  of  alopecia.  But 
the  hair  in  syphilis  is  less  affected  than  in  favus,  and 
when  it  falls  it  gives  the  head  a  ragged  appearance,  as 
if  the  hair  had  been  cut  off  in  an  irregular  manner 
with  a  pair  of  dull  shears.  There  are  no  crusts,  and 
there  is  a  history  of  an  initial  lesion  and  a  general 
eruption.  When  the  baldness  is  due  to  a  late  ulcerat- 
ing lesion  the  history  will  be  distinct,  and  the  cicatrix 
well  marked.  The  other  forms  of  baldness  will  be 
sufficiently  distinguished  by  the  history  of  their  onset 
and  course,  and  the  absence  of  all  the  other  characteris- 
tics of  favus. 

In  doubtful  cases  the  finding  of  mycelia  and  conidia 
in  crusts  and  hair  will  positively  exclude  eczema, 
seborrhoea,  psoriasis,  lupus,  and  alopecia.  If  a  case 
presents  itself  with  thick  crusts;  or,  if  b}^  reason  of 
cleanliness,  it  has  only  red,  bald  patches,  and  we  are 
told  that  it  has  lasted  for  some  .time  and  is  very  scaly, 
we  can  determine  the  presence  or  absence  of  favus 
by  letting  the  disease  follow  its  own  course  for  a  time, 
and  watching  it.  Of  course  all  the  crusts  that  may 
be  present  must  be  removed.  In  the  course  of  two 
or  three  weeks  or  less,  if  the  case  be  one  of  fa\"us,  we 


270  DISEASES  OF  THE   HAIR  AND   SCALP. 

will  notice,  at  first,  little  red  spots  upon  the  scalp,  and 
later  the  development  of  cupped  crusts. 

Prognosis. — Though  the  disease  is  obstinate  to  treat- 
ment, still  it  is  perfectly  curable  when  handled  with 
intelligence  and  perseverance.  A  promise  of  speedy 
cure  should  never  be  given,  as  it  is  always  a  matter  of 
months,  and  sometimes  of  years.  Even  after  the  dis- 
ease is  apparently  cured,  we  should  have  the  patient 
present  himself  for  inspection  at  intervals  of  a  few 
weeks  during  a  year.  Unfortunately  we  can  do  noth- 
ing to  remedy  the  damage  done  to  the  scalp  in  the 
foi'mation  of  bald  patches.  These  are  permanent, 
though  they  will  become  less  disfiguring  by  time,  as 
the  redness  gradually  fades. 

Treatment. — In  the  treatment  of  favus  patience  and 
method  are  of  more  value  than  any  special  medica- 
tion. Without  perseverance  on  the  part  both  of  phy- 
sician and  patient  it  will  be  impossible  to  cure  a  case. 
Epilation,  cleanhness  and  parasiticides  are  the  means 
at  our  command  for  combating  the  disease. 

The  first  thing  to  be  done  is  to  clean  the  scalp  of 
all  crusts.  This  is  accomplished  by  keeping  the  whole 
scalp  soaked  in  oil  for  a  day  or  two,  according  to  the 
thickness  of  the  crust,  and  then  washing  with  an 
abundance  of  soap  and  water.  For  an  oil  we  may 
choose  either  sw^eet  or  ohve  oil,  or- oil  of  sweet  almonds, 
and  it  is  useful  to  add  some  parasiticide  to  the  oil, 
such  as  carbohc  acid  gr.  xv  ad  3  j ;  or  salicyhc  acid, 
three  per  cent.  Or  we  may  use  a  poultice  to  remove 
the  crusts,  though  this  is  a  more  disagreeable  method. 
When  the  crusts  have  been  got  rid  of  we  must  epi- 
late,  and  prevent  the  new  formation  of  ci-usts  by 
the  use  of  our  chosen  parasiticide,  and  by  washing,  at 
intervals,  with  soft  soap  or  the  tincture  of  green  soap. 
As  a  rule  it  is  best  to  allow  the  parasiticide  to  remain 


FAVUS.  271 

undisturbed  upon  the  scalp,  and  not  to  wash  the  head 
more  than  once  or  twice  a  week. 

The  most  important  means  of  cure  is  epilation,  which 
may  be  accomplished  by  one  of  three  methods:  1.  By 
the  pincette  or  epilating  forceps;  2.  By  Kaposi's  (19) 
method;  and  3.  By  the  "  calotte,"  or  by  the  epilating 
stick,  which  is  a  modification  of  the  calotte. 

The  first  method,  or  that  of  the  forceps,  is  the  one 
most  commonly  employed,  and  when  systematically 
carried  out,  is  thoroughly  reliable.  Care  must  be  given 
to  the  selection  of  the  forceps.  They  should  have  an 
easy  spring  and  their  edges  should  accurately  coapt. 
I  prefer  to  have  the  blades  grooved  transversely  on 
their  inner  face,  as  the  hair  is  more  firmly  held  by  a 
roughened  than  by  a  smooth  blade.  Each  hair  must 
be  plucked  out  from  the  diseased  patch  and  from  a 
little  area  around  it.  The  operator  should  begin  at 
one  portion  of  the  patch  and  clear  off  a  small  part 
every  day,  each  hair  whether  sound  or  unsound  being 
pulled  out  by  a  rapid  jerk  of  the  hand  in  the  direction 
in  which  it  grows.  The  chosen  parasiticide  should  be 
applied  immediately  to  the  part  epilated. 

Kaposi's  (19)  method  has  for  its  object  the  epilation 
of  the  diseased  hairs  alone.  When  the  forceps  is  used, 
both  the  sound  and  the  unsound  hairs  are  pulled  out. 
Of  course  it  is  desirable  to  spare  the  soimd  hairs,  and 
Kaposi  maintains  that  if  little  bmiches  of  the  hair  are 
pulled  between  the  thumb  and  some  firm  object,  such  as 
a  straight  spatula,  held  within  the  grasp  of  the  fingers 
enough  traction  will  be  exercised  to  extract  the  loos- 
ened and  diseased  hairs,  but  not  enough  to  disturb  the 
healthy  and  firmly  seated  hairs.  This  is  Kaposi's 
method,  which  has  given  him  satisfaction.  It  is  rapid, 
and  less  painful  than  any  other  mode  of  epilating. 

The  ^'  caZo^fe,"  or  pitch -cap,  is  the  most  rapid  means 
of  epilating,  but  is  i)ainful  and  sometimes  dangerous. 
The  "calotte"  is  composed  of, 


272  DISEASES  OF  THE  HAIR  AXD  SCALP. 

Vinegar,  .        .        .        .  150  parts. 

Wheat  flour,  ....  25       '^ 

Black  pitch,  ....  25       '^ 

White  pitch,  .         .         .         .  25       " 

made  into  a  mass  and  spread  on  leather.  This  is  ap- 
plied, while  soft,  to  the  whole  head,  and. when  it  has  set, 
it  is  pulled  off  suddenly  hy  taking  hold  of  the  part  over 
the  forehead,  and  removing  it  from  hef  ore  hackwards. 
Its  use  was  abandoned  on  account  of  some  unfortunate 
accidents.  Since  then  various  epilating  sticks  have 
been  invented  to  take  its  place.  One  of  these  much 
used  by  Bulkley  (53S)  is  composed  of 

CerrP  flavae,  .  .  3  iij  say  10. 

Lacc^e  in  tabuhs,  ,  .  3  iv      ''  15. 

Picis  burgundicae,  .  .  3x        "  35. 

Gummi  damar,  .  .  §  iss      ^'  40. 

These  are  made  into  a  mass  and  cast  in  sticks  from 
half  an  inch  to  an  inch  in  diameter  and  two  inches  in 
length.  One  end  is  heated  and  apphed  with  a  sort  of 
boring  movement  to  the  part  to  be  epilated.  When 
cold  it  is  removed  by  a  sudden  twisting  motion.  The 
hair  will  be  found  sticking  to  the  end,  and  must  be  re- 
moved by  burning  before  the  stick  can  be  used  again. 
Several  sticks  may  be  employed  at  once  to  a  large 
patch.  For  hospital  or  dispensaiy  work  these  epilat- 
ing sticks  are  serviceable,  but  are  rather  harsh  for 
private  practice. 

Whatever  method  is  used  it  must  be  faithfully  car- 
ried out.  A  skilled  nurse  should  be  employed  for  the 
work,  and  where  such  is  not  attainable,  the  physician 
must  make  it  his  duty  either  to  do  the  epilating  him- 
self, or  to  train  some  member  of  the  family  for  the 
work. 


J^AVUS.  273 

Parasiticides  are  next  in  importance  to  epilation,  and 
should  be  applied  after  that  procedure,  not  only  to  the 
part  epilated  but  to  the  whole  scalp;  the  latter  in  order 
to  prevent  the  spread  of  the  disease.  There  are  many 
excellent  ones  from  which  to  choose,  such  as  a  half  per 
cent,  solution  of  bichloride  of  mercury  in  ether  or 
alcohol;  the  oleate  of  mercury  or  copper;  the  essential 
oils;  tar;  oil  of  cade;  creosote  in  ethereal  or  alcoholic 
solution,  or  in  oil;  sulphurous  acid  in  full  strength; 
carbolic  or  salicylic  acid,  3  to  5  per  cent,  in  oil;  the  oint- 
ments of  the  ammoniate  or  yellow  sulphate  of  mercury; 
and  various  others.  Ointments  or  solutions  of  thymol, 
napthol,  pyrogallol,  or  chrysarobin  in  five  to  ten  per 
cent,  strength,  are  among  the  newer  remedies.  Hyde 
(18)  quotes  Lenzberg  as  saying  that  he  had  never  failed 
to  cure  a  case  of  f  avus  without  epilation  by  generating 
sulphur  fumes,  carrying  them  to  the  head  by  means  of 
a  paper  cap,  and  continuing  the  fumigation  for  five  or 
ten  minutes.  Peroni  (390  ap.)  recommends  spraying 
the  scalp  with  acetic  acid.  If  this  causes  excoriations 
they  are  to  be  treated  with  diachylon  ointment,  and 
when  healed  the  scalp  is  to  be  washed  with  warm 
water  and  sublimate  soap. 

Sawicki  (572)  recommends  cutting  the  hair  short  and 
covering  the  whole  scalp,  crusts  and  all,  with  a  paste 
made  out  of  powdered  chalk  or  gypsum  with  iive  or 
ten  per  cent,  of  carbolic  acid.  The  paste  is  to  be  lai  1 
on  0.5  cm.  thick,  and  the  head  bound  with  a  damp 
cloth.  In  three  days  the  whole  is  removed,  the  scalp 
washed  with  a  potash  soap,  and  the  dressing  reapplied. 
Three  or  four  applications  are  said  by  him  to  effect  a 
cure.  The  oil  of  naptha  has  been  used  from  time  to 
time,  applied  morning  and  night,  after  washing  the 
scalp  with  soap  and  water.  This  often  proves  irritat- 
ing. Unna  (i93a)  has  recently  recommended  icthyol 
in  the  form  of  spray  for  favus.     Ihle  (55-I-)  cured  one 


274:  DISEASES  OF   THE   HAIR   AND   SCALP. 

case  in  two  mouths  by  means  of  a  five  per  cent,  resor- 
cin  ointment.  I  have  seen  as  satisfactory  results  from 
epilation  and  the  use  either  of  a  three  to  five  per  cent, 
solution  of  salicylic  acid  in  castor  oil,  kept  constantly 
applied,  or  from  the  constant  and  persistent  use  of 
sulphur  ointment,  as  from  any  other  plans  of  treat- 
ment. 

The  treatment  of  fa vus  consists  then,  in  1st.  Cleaning 
the  scalp;  2nd.  Epilating;  3d.  Applying  a  parasiticide. 
These  procedures  must  be  repeated  again  and  again, 
and  the  whole  diseased  portion  of  the  scalp  worked 
over  and  over,  until  the  hair  is  apparently  growing  in 
a  healthy  manu'^r  and  the  scalp  is  free  from  reddish 
points  freshly  cropping  out.  Then  the  scalp  should  be 
left  entirely  alone  for  a  few  weeks.  At  the  end  of  that 
time  it  should  be  mspected,  some  hairs  examined 
under  the  microscope,  and  if  there  is  no  sign  of  the  dis- 
ease present,  the  case  may  be  discharged.  Even  then 
the  patient  should  be  examined  from  month  to  month 
for  some  months,  to  make  sure  of  the  dm-abihty  of  the 
cure. 


CHAPTER  XVI. 

PEDICULOSIS  CAPITIS. 

Synonyms: — Phthiriasis;  Phtheiriasis;  Morbus  pedic 
ularis;    Pedicularia;   Malis  pediculi;   Pediculosis  cai)il- 
litii;  Lousiness  (Eng.);  Lausesucht  (Ger.);   Phthiriase, 
ou  Maladie  pediculaire  (Fr.). 

Definition. — A  contagious  disease  of  the  hairy  scalp 
due  to  its  invasion  by  lice.  It  is  characterized  by  the 
presence  of  the  lice  and  their  ova  upon  the  scalp  and 
hair;  by  the  wounds  inflicted  by  their  probosces;  by 
pruritus;  and  by  lesions  consequent  upon  scratching. 

Symptoms. — The  attention  of  the  patient  is  first 
drawn  to  his  disease  by  itching  of  the  scalp,  due  to  the 
irritation  produced  by  the  louse  in  its  endeavor  to  ob- 
tain its  nourishment  from  the  skin,  which  it  does  by 
inserting  its  proboscis  into  the  follicles;  and  by  its 
moving  about  on  the  scalp  and  hair.  The  amount  of 
itching  varies  with  the  susceptibility  of  the  individual, 
with  the  number  of  the  Hce  present,  and  with  the  ex- 
tent and  duration  of  the  disease.  One  louse  will  cause 
as  much  itching  in  one  individual  as  a  whole  army  of 
them  will  give  rise  to  in  another.  In  susceptible  indi- 
viduals, and  in  aggravated  cases,  the  itching  may  be  so 
intense  as  to  cause  loss  of  sleep,  and  consequent  loss  of 
health,  emaciation,  and  such  constitutional  symptoms 
as  to  constitute  a  grave  disease.  The  itching  always 
induces  scratching,  and  the  inibbing  and  tearing  of  the 
scalp  by  the  nails  give  'rise  to  the  lesions  of  the  dis- 
ease. These  are  either  merely  excoriations,  or  isolated 
pustules,  or  a  veritable  pustular  eczema,  varying  with 
the  individual.     People  who  are  in  bad  hygienic  sur- 


270  DISEASES   OF   THE   HAIR   AND   SCALP. 

roimdings,  poorly  nourished,  uncleanly,  and  of  stru- 
mous habit  present  the  most  pronounced  lesions. 

The  pai-t  of  the  scalp  most  frequently  affected  is  the 
occipital  region.  The  parietal  regions  stand  next  in 
order  of  invasion,  but  always  in  conjunction  with  the 
occipital  region.  In  the  vast  majority  of  cases  the 
disease  is  hniited  to  these  locahties,  but  sometimes  the 
whole  head  is  affected,  and  in  bedridden,  uncleanly  in- 
dividuals the  head-hce  may  be  found  on  the  trunk. 

The  picture  i^resented  by  a  well-marked  case  of  pedi  • 
culosis  capitis  is  the  following:  On  hfting  the  hair 
from  the  back  of  the  head  a  reddened,  oozing,  excori- 
ated, ciTisted  patch  of  varying  size  is  uncovered,  with 
outlying  pustules,  and  cutaneous  abscesses  or  furun- 
cles, a  veritable  pustular  eczema  of  liigh  grade.  The 
hak  is  matted  together  by  the  exudation,  and  myriads 
of  Hce  will  be  seen  running  around  amongst  it  and 
crawhng  along  the  hairs.  There  will  be  multitudes  of 
ghstening  white  or  yellowish  ova  firmly  attached  to 
the  hair  shafts,  sometimes  quite  near  the  scalp,  some- 
times at  long  distances  from  it.  Over  the  whole  scalp 
we  will  find  isolated  pustules,  fmiincles,  excoriations, 
and  patches  of  eczema.  The  post-cervical  glands  will 
be  enlarged,  there  will  often  be  patches  of  eczema  be- 
hind the  ears  and  upon  the  face  and  neck,  and,  ac- 
cording to  Kaposi  (19),  pemphigus -like  blebs  may  occur 
upon  the  face. 

Pediculosis  may  occur  alone  or  it  may  compHcate 
other  diseases  of  the  scalp,  such  as  eczema,  favus,  and 
trichophytosis 

Etiology.— The  head  louse  is  the  only  cause  of  the 
disease,  and  this  is  always  derived  from  some  other 
individual  sufferiug  with  phthiriasis.  It  used  to  be 
thought  that  hce  were  the  product  of  an  eczema  or  other 
disease  of  the  scalp,  but  this  view  is  no  longer  tenable. 
It  gained  its  support  from  the  presence  of  an  eczema 


PEDICULOSIS    CAPITIS.  277 

in  the  cases  observed.  But  though  eczema  does  not 
produce  hce,  an  existing  eczema  may  favor  their 
invasion,  providing  for  them  a  good  and  convenient 
feeding  ground. 

The  disease  is  met  with  most  frequently  amongst 
the  poor,  but  the  better  classes,  even  those  who  are 
most  cleanly,  are  not  exempt.  Thus  Bulkley  met  with 
228  cases  of  the  disease  in  8,000  cases  of  skin  diseases, 
of  which  7  occurred  in  private  practice.  It  is  more 
frequent  than  is  pediculosis  corporis,  as  Bulkley 'stables 
show.  He  met  with  but  IttT  cases  of  the  latter  against 
228  of  the  former.  Children  suffer  from  the  disease 
more  than  adults,  and,  among  adults,  women  more 
frequently  harbor  the  vermin  than  do  men.  Infants 
at  the  breast  are,  usually,  exempt  from  the  disease;  I 
have  seen  but  few  cases  in  them.  The  reason  for  the 
exemption  of  infants  is  found  in  the  scantiness  of  their 
hair,  and  the  greater  care  that  is  bestowed  upon  them. 
Women  wear  their  hair  long  and  their  skin  is  more 
tender  than  is  that  of  men;  they  therefore  form  a  more 
favorable  lodgment  for  the  lice  than  men  do,  and  are 
more  often  affected. 

The  cause  of  the  lesions  of  the  scalp  in  phthiriasis 
is  the  scratching,  nature's  plan  for  allaying  the  itching. 
The  swollen  glands  are  sympathetic  with  the  inflam- 
mation of  the  scalp;  they  are  commonly  met  with  in 
all  inflammatory  diseases  of  the  scalp. 

The  louse  does  not  bite,  as  it  has  neither  mouth  nor 
mandibles,  but  simply  inserts  his  haustellum  into  the 
follicles  of  the  skin  and  sucks  its  food  from  the  deeper 
parts.     Thus  it  is  improper  to  speak  of  louse-bites. 

Pathology. — The  pathology  of  this  disease  is  con- 
cerned mainly  with  the  louse  itself.  The  pathology  of 
the  lesions  of  the  disease  is  the  same  as  that  of  artifi- 
cial eczema  of  the  scalp,  or  a  common  traumatic  der- 
niatitis. 


27s  DISEASES   OF   THE   HAIR  AND   SCALP. 

There  are  three  distinct  varieties  of  Uce  which  infest 
the  human  body.  1.  The  pediculus  vestimenti  sen 
corporis.  2.  The  pediculus  capitis.  3.  The  pediculus 
pubis.  Each  has  its  own  province,  out  of  which  it 
rarely  passes. 

The  body  louse  resides  in  the  clothing,  which  it  leaves 
only  to  draw  its  food  from  the  wearer  of  the  same. 
This  genus  of  louse  does  not  concern  us  here.  The 
pubic  louse  is  found  mostly  on  the  pubes,  rarely  on  the 
scalp,  and  will  be  described  in  the  next  chapter.  We 
have  here  to  do  with  the  head  louse  alone.  The  male 
pediculus  capitis  is  from  1  to  2  mm.  long  (according  to 
Neumann  (27)  it  is  3  to  5  mm.  long)- 
^  V^V_J^  and  from  0.6  to  1  mm.  broad:  the  fe- 
^"^  ^"^^"^^  male  is  larger  by  a  few  millimetres. 
It  is  smaller  than  the  body  louse,  and 
larger  than  the  pubic  louse.  Its  head 
is  triangular  in  shape;  its  body  forms 
an  elongated  oval  whose  outline  is 
scalloped  with  seven  deep  notches.  It 
has  three  pairs  of  legs,  situated  well 
Pediculus  capitis,  f^^ward  at  the  sides  of  the  thorax, 
and  these  have  powerful  joints  and  strong  claws. 
The  legs  are  covered  sparsely  with  bristly  hairs.  Two 
fine- jointed  antennae  come  off  from  the  head.  The  color 
of  the  louse  is  gray  with  black  outlines.  The  color 
varies  ^\ith  the  race.  Thus  in  the  Esquimaux  it  is 
white,  in  the  Negro  black,  and  in  the  Chinese  yellow- 
isli  brow^n.  The  ova  or  '^  nits"  are  about  one  quarter 
of  a  line  long,  are  of  oval  or  pear-shape,  and  of  gray 
color.  They  are  found  in  great  abundance  glued  to 
the  hair-shaft,  one  hair  bearing  anywhere  from  one 
to  four  or  more,  the  lower  one  being  the  youngest. 
They  are  first  laid  by  the  female  along  the  lower  part  of 
the  hair- shaft,  and  then  are  carried  further  away  from 
the  scalp  by  the  growing  hair.     They  are  difficult  to  re- 


PEDICULOSIS  CAPITIS.  279 

move  and  are  arranged  along  the  hair  hke  grapes  upon 
a  stem. 

The  female  is  very  prolific,  laying  from  fifty  to  sixty 
eggs.  The  young  hatch  out  in  six  days,  and  within 
seventeen  to  twenty  days  are  capable  of  propagating. 
This  accounts  for  the  rapidity  of  spread  of  the  disease, 
one  louse  being  capable  of  producing  8000  lice  in  eight 
weeks. 

Diagnosis.— Pediculosis  capitis  is  most  apt  to  be 
mistaken  for  an  eczema  of  the  scalp,  and  is  not  infre- 
quently treated  with  ointments,  such  as  that  of  the 
oxide  of  zinc,  wiiich  only  add  the  element  of  rancid 
lard  to  the  already  disgusting  condition  present.  This 
mistake  need  never  occur  if  we  bear  in  mind  that  an 
eczema  of  the  occipital  region  is  due,  in  an  over- 
whelming majority  of  cases,  to  Hce.  In  every  such 
case  then,  look  for  the  vermin,  and  you  will  find  them 
or  their  nits,  if  the  case  is  one  of  pediculosis.  In  some 
cases  where  only  itching  of  the  scalp  is  complained  of 
and  the  patient  is  very  careful  of  his  scalp,  we  may 
find  neither  eczema  nor  lice,  but  simply  some  little 
grayish  bodies  fastened  on  the  hairs.  These  may  be 
epithelial  scales  or  sebaceous  masses  perforated  by 
hairs,  a  not  uncommon  condition;  or  they  may  be  nits. 
The  doubt  is  readily  settled  by  attempting  to  remove 
them.  If  they  are  epithelial  or  sebaceous  particles  they 
will  be  easily  removed  by  brushing.  If  they  are  ova 
they  will  resist  the  brush,  and  sometimes  the  comb, 
and  often  will  require  the  application  of  some  agent, 
such  as  acetic  acid,  to  dissolve  their  connection  with 
the  hair. 

Prognosis. — The  disease  is  rapidly  and  completely 
cured  by  appropriate  treatment. 

Treatment. — The  promptest,  cheapest,  and  most 
readily  obtainable  remedy  for  pediculosis  capitis  is 
crude  petroleum  or  common  kerosene  oil.     The  head 


280  DISEASES   OF   THE   HAIR  AND   SCALP. 

is  to  be  saturated  with  this  for  a  day  or  two,  and  then 
well  washed  w4th  an  abundance  of  soap  and  water. 
This  will  destroy  the  lice,  but  will  not  prevent  the 
hatching  out  of  the  ova.  Tliese  are  to  be  removed  by 
the  fine  comb,  care  being  taken  not  to  touch  the  scalp, 
and  by  pulling  the  hair  through  a  towel  saturated  with 
vinegar  or  dilute  acetic  acid.  By  patience  all  the  nits 
may  be  removed.  As  a  precautionary  measure  the 
scalp  should  be  well  wetted  with  kerosene  for  a  few 
days,  after  it  is  apparently  well,  to  insure  the  death  of 
any  louse  which  may  have  hatched  from  a  missed  nit. 
The  objections  to  this  plan  are  the  danger  of  fire,  and  the 
unpleasant  odor.  The  first  objection  may  be  met  by 
cautioning  the  patient  to  keep  away  from  the  fii'e;  or 
the  danger  may  be  reduced  by  mixing  the  petroleum 
with  some  other  oil,  such  as  olive  oil.  The  second 
objection  is  overcome  by  adding  some  perfume  to  the 
oil.  But  this  is  only  partially  effective,  and  the  plan 
with  all  its  excellencies  cannot  be  used  in  j^i'i^ate 
practice. 

It  is  always  preferable  to  use  lotions  rather  than 
ointments  in  treating  pediculosis  capitis.  Ointments 
are  apt  to  mat  the  hair  together  and  to  become  rancid. 
There  are  many  drugs  and  chemicals  that  destroy  lice. 
One  of  the  most  desirable  for  use  in  private  practice, 
and  in  adults,  is  a  solution  of  bicliloride  of  mercury,  two 
or  five  gi-ains  to  the  ounce  of  cologne  water  or  bay 
rum,  sopped  on  several  times  a  day.  This  is  poisonous 
and  had  best  not  be  used  on  the  heads  of  children,  and 
is  contraindicated  where  there  is  eczema.  In  children 
a  good  substitute  is  carbolic  acid,  ten,  twenty  or  more 
drops  to  the  ounce  of  alcohol,  to  which  a  little  glycerine 
may  be  added.  Larkspur  seed  {staphisagria)  can  be 
readily  obtained,  and  a  strong  decoction  of  it  will  be 
found  a  quick  and  sure  destroyer  of  hce.     Instead  of  the 


PEDICULOSIS  CAPITIS.  2S1 

decoction  the  tincture  may  be  employed.  Napthol, 
five  per  cent,  in  oil,  is  another  good  remedy.  The 
essential  oils  will  kill  lice.  The  decoction  or  tincture 
of  cocculus  indicus  enjoys  a  repute  tion  of  the  same 
sort.  A  five  or  ten  per  cent,  salicylated  oil  may  be 
used.  Instead  of  a  lotion  we  may  use  an  ointment, 
especially  where  there  is  considerable  irritation  of  the 
scalp  and  an  artificial  eczema.  One  of  the  best  is  that 
of  the  ammoniate  of  mercury  made  with  vaseline  in 
twenty  per  cent,  strength.  Where  eczema  is  present, 
we  want  to  kill  the  lice  first,  when  it  will  be  an  easy 
matter  in  most  cases  to  cure  the  eczema.  These  ecze- 
matous  heads  with  lice  will  often  bear  kerosene  very 
well.  After  the  vermin  has  been  destroyed  by  the 
kerosene,  the  application  of  oil  of  cade,  one  drachm  to 
olive  oil  one  ounce,  will  act  admirably  upon  the  eczema 
and  at  the  same  time  be  a  parasiticide. 

An  ointment  of  sulphur  is  efficient,  as  is  also  one  of 
sabadilla.  The  latter  should  not  be  used  upon  a  sore 
head  as  it  may  cause  dangerous  symptoms  of  poison- 
ing. All  the  ointments  of  mercury  will  render  good 
service.  An  ointment  of  tobacco  w^ill  destroy  the 
pediculi,  but  it  is  too  disagreeable  for  use  except  when 
nothing  else  is  available.  Chrisma,  a  derivative  of 
petroleum,  has  been  indorsed  by  Crane  as  an  active 
parasiticide.  (587.) 

Instead  of  ointments  some  recommend  powdering 
the  hair  with  either  calomel,  pyrethrum  roseuni 
(Persian  insect  powder),  powdered  seeds  of  wormwood, 
rue,  or  parsley.  But  in  my  judgment  ointments  and 
powders  are  all  objectionable.  If  an  ointment  must 
be  used,  then  it  is  better  to  have  it  made  with  vaseline 
rather  than  with  lard,  as  it  is  less  Hable  to  mat  the 
hair.  In  all  cases  soap  and  water  should  be  used  for 
washing,  and  this  should  be  done  daily,  excepting 


282  DISEASES   OF  THE   HAIR  AND   SCALP. 

where  eczema  is  present,  when  water  is  contraindi- 
cated.  In  all  cases  the  nits  are  to  be  removed  with  the 
greatest  care,  and  we  must  impress  upon  the  patient 
or  the  attendant,  that  as  long  as  there  is  a  single  nit, 
there  is  danger  of  a  new  outbreak.  The  nits  may  be 
removed,  as  already  stated,  by  means  of  vinegar,  or 
acetic  acid,  which  is  the  best.  To  the  same  end  alco- 
hol, and  alkaline  solutions,  as  of  borax  or  soda  or  the 
tincture  of  green  soap,  may  be  used. 


CHAPTER  X\^II. 

PEDICULOSIS  PUBIS  ET  PALPEBRARUM. 

These  two  diseases  are  caused  by  the  same  species  of 
louse,  the  Phthirius  inguinahs,  or,  as  commonly  called, 
crab  louse.     We  will  first  consider, 

PEDICULOSIS  PUBIS. 

Symptoms. — When  the  louse  has  taken  up  its  habita- 
tion upon  the  pubes  it  begins  to  propagate  in  the  same 
energetic  way  we  have  learned  of  in  the  preceding 
chapter;  and  to  insert  its  haustellum  into  the  foUicles 
of  the  skin  and  suck  its  nourishment  therefrom.  The 
movements  of  the  lice  upon  the  hair,  and  the  irritation 
caused  by  their  puncturing  the  skin,  give  rise  to  itching, 
which  the  patient  tries  to  allay  by  scratching.  The 
itching  is  at  times  intense,  specially  at  night,  but  is 
usually  not  so  violent  as  in  pediculosis  capitis,  though 
it  is  as  persistent.  As  a  rule  there  is  no  great  amount 
of  dermatitis  or  eczema  present,  and  it  is  rare  to  see 
such  a  picture  presented  as  we  constantly  meet  with  in 
pediculosis  capitis.  This  may  be  accounted  for  by  the 
fact  that  the  pubic  region  must  be  scratched  for  the 
greater  part  of  the  time  through  the  clothes,  while 
the  scalp  is  readily  accessible  to  the  nails.  If  the  lice 
are  present  in  very  gi^eat  number,  or  the  patient's  skin 
is  very  vulnerable,  we  may  have  a  well-marked  eczema. 
The  patient  usually  applies  to  the  physician  on  account 
of  a  pi-uritus  of  the  genital  region,  and  in  the  majority 
of  cases,  is  not  conscious  of  having  lice  on  liim.     In  all 


^84  DISEASES   OF  THE   HAIR   AND   SCALP. 

cases  of  itching  about  the  genitals  it  is  imperative  to 
make  an  examination  of  the  parts.  If  Hce  are  present 
we  will  And  them  as  small,  flat,  translucent,  brownish 
or  reddish  specks  close  down  to  the  skin  and  chnging 
to  the  roots  of  the  hair.  Their  position  is  character- 
istic. They  usually  are  found  with  their  heads  buried 
in  a  skin- follicle,  their  claws  firmly  fastened  about  a 
hair,  and  their  hinder  parts  sticking  up  in  the  air.  At 
times  one  may  be  found  moving  about  upon  the  hair, 
but  they  are  far  less  active  than  the  hce  which  infest 
the  head  and  clotliing.  Besides  the  lice,  we  will  find 
their  excrement  lying  amongst  the  hair-roots  in  the 
form  of  minute  reddish  particles;  and  their  ova  upon 
the  hair.  As  has  already  been  said,  we  may  find  a  well 
marked  eczema  of  the  pubic  region.  This  is  excep- 
tional. But  we  constantly  see  red,  punctate  macules 
or  papules  scattered  about,  which  are  scratch  marks. 
Now  and  again,  but  not  constantly,  we  will  see  dull  or 
slaty  gi'ay,  or  peculiar  pale  blue  macules,  varying  in 
size  from  that  of  a  lentil  to  that  of  a  split  pea  or  larger, 
scattered  over  the  regions  infested  by  the  lice,  as  over 
the  pubes,  abdomen,  and  inside  of  the  thighs.  These  do 
not  disappear  on  pressure;  they  last  for  a  few  days 
and  then  vanish  of  themselves.  They  are  known  as 
macuJce  cerulece  or,  in  French,  tdches  omhrees.  They 
are  unaccompanied  by  any  subjective  symptoms. 

Tlie  pubic  louse  is  more  nomadic  than  any  of  its 
congeners.  While  it  is  most  frequently  found,  as  its 
name  indicates,  upon  the  pubic  region,  it  is  not  infre- 
quently met  with  upon  other  parts  of  the  body  sup- 
phed  with  hair,  as  upon  the  thighs,  about  the  anus,  on 
the  abdomen,  thorax,  and  arms,  in  the  axillae,  occa- 
sionally upon  the  eye-brows,  eyelashes  and  beard,  and 
sometimes  on  the  arms.  In  aU  these  situations  it  gives 
rise  to  the  same  symptoms  as  when  on  the  pubes,  and 
we  must  be  on  the  watch  for  it  in  all  cases  of  pruritus 


PEDICULOSIS   PUBIS   ET   PALPEBRARUM. 


1>S5 


in  those  regions.  It  is  not  found  on  the  scalp.  Adults 
are  the  subjects  of  the  disease  in  the  vast  majority  of 
cases. 

Etiology.— The  cause  of  the  disease  is  the  infesting 
of  the  part  with  the  pubic  louse.  The  infection  most 
commonly  is  effected  during  sexual  intercourse.  It  is 
also  acquired  by  sleeping  with  an  infected  individual  or 
in  a  bed  already  infected  by  some  one  ;  and  by  wearing 
infected  clothing.  It  is  quite  possible  for  the  vermin  to 
infest  a  woman  in  public  conveyances,  on  account  of  the 
peculiar  make  of  her 
clothing.  A  man's 
clothing  affords  bet 
ter  protection.  Pif- 
FARD  (29a)  thinks  that 
it  is  possible  to  ac- 
quire the  disease  in 
water-closets.  It  is 
much  rarer  than  are 
the  other  forms  of  pe- 
diculosis. BULKLEY 
records  but  8  cases  in 
8,000  cases  of  skin  dis- 
eases. The  tables  would  indicate  that  it  is  proportion- 
ately more  common  in  private  practice  than  are  the 
other  forms,  as  of  the  8  cases  met  with,  three  were  in 
private  practice  and  five  were  in  public  practice. 

Pathology. --The  pathology  of  this  affection  is  the 
same  as  that  of  pediculosis  capitis  with  but  two  excep- 
tions, and  those  are  the  characteristics  of  the  louse, 
and  the  macula3  ceruleae.  These  alone  will  require 
notice  here. 

The  Pubic  Louse, — synonyms  :  pediculus  pubis  sen 
ferox,  phthirius  inguinalis,  morpio,  f oralis  pediculus; 
morpion  (Fr.);  die  Filzlaus  (Ger.);  Crabs  (Eiig.), — 
has  a  less  triangular  and  more  broad  head  than  the 


Pediculus  pubis. 


286  DISEASES  OF  THE   HAIR  AXD   SCALP. 

other  species  of  louse,  and  a  well-marked  neck.  Its 
body  is  heart-shaped,  and  its  eight  segments  are  not 
clearly  indicated  by  notches  in  its  outhne,  as  is  tlie 
case  with  the  head  louse.  It  has  three  pairs  of  legs 
which  come  off  from  its  thorax,  of  which  the  anterior 
pair  are  proportionately  dehcate,  and  bear  only  a  small 
claw  at  their  ends.  The  two  other  pairs  have  a  stout 
hook-shaped  claw.  The  male  is  from  0.8  mm.  to  1.0 
mm.  long,  and  from  0.5  mm.  to  0.7  mm.  wide;  and 
the  female  is  from  1.0  mm.  to  1.5  mm.  larger.  The 
female  has  a  triangular-shaped  notch  at  the  termina- 
tion of  the  abdomen.  From  the  head  of  the  louse 
project  two  fine- jointed  antennae.  The  color  of  the 
louse  is  yellowish  gray;  and  it  is  more  or  less  trans- 
parent. 

Maculae  ceruleae  have  long  been  known,  but  until 
very  recent  times  their  significance  has  been  misunder- 
stood, and  they  have  been  considered  as  symptomatic 
of  grave  fevers,  such  as  typhus  fever. 

MouRSON  (591)  was  the  first,  in  1878,  to  draw  atten- 
tion to  the  connection  between  these  spots  and  the 
presence  of  hce.  He  showed  that  while  everyone  who 
has  pediculosis  pubis  does  not  have  the  maculae,  yet 
everyone  upon  whom  the  maculae  are  fomid  has  the 
pediculi,  or  has  had  them  shortly  before  presenting  for 
examination.  They  were  found  more  commonly  in 
those  who  had  fine  skins  and  did  not  wash  often. 
They  are  fuiiher  j^roved  to  be  due  to  the  hce  by  the 
fact  that  if  only  one  axiUa  was  affected  with  hce, 
they  would  be  found  in  that  axiUa  alone,  the  other 
being  free.  Most  of  the  cases  have  been  found  in 
patients  suffering  from  some  debilitating  disease,  and 
their  gi^eat  rarity,— Gibier  (580)  failed  to  find  a  single 
case  in  Iavo  hundred  subjects  of  pediculosis, — would  in- 
dicate that  some  predisposition  on  the  pai-t  of  the  skin 
is  a  requisite  for  their  formation.     The  causal  connec- 


PEDICULOSIS  PUBIS  ET  PALPEBRARUM.  2S^ 

tion  between  the  pediculi  and  the  maoulai  having  been 
estabhshed,  it  next  remained  to  determine  how  they 
were  produced.  Duguet  (588),  in  1880,  obtained  the 
same  appearances  by  pricking  the  skin  with  a  lancet 
point  charged  with  a  paste  made  by  rubbing  up  the 
bodies  of  twenty-five  hce.  Bat  he  could  produce  the 
maculae  only  in  individuals  already  bearing  them  ;  an- 
other indication  of  the  part  idiosyncrasy  plays  in  the 
disease.  He  believes  that  the  maculae  are  caused  by 
the  emptying  of  the  contents  of  the  salivary  glands  of 
the  louse  beneath  the  epidermis  of  the  human,  uncon- 
nected with  any  further  alterations  in  the  skin.  These 
spots  spontaneously  disappear  in  about  ten  days. 

Diagnosis.— The  detection  of  the  louse  or  its  nits 
will  at  once  give  the  diagnosis.  It  is  for  us  only  to 
look  for  the  evidence  of  pediculi  in  every  case  of  pruri- 
tus cutaneous,  especially  when  such  pruritus  is  limited 
to  the  pubic  or  axillary  regions.  We  should  suspect 
and  carefully  look  for  lice  in  all  cases  of  eczema  limited 
to  the  pubis,  and  even  in  eczema  of  the  genitals  and 
thighs.  The  pediculus  pubis  is  less  easy  of  detection 
than  are  the  other  species  of  louse  on  account  of  its 
small  size,  light  color,  translucency,  greater  quiescence, 
and  more  or  less  perpendicular  position  as  it  lies  deep 
down  among  the  hair-roots.  Still  if  one  is  but  alive  to 
the  possibility  of  the  vermin  being  present,  he  will 
have  no  difficulty  in  detecting  them  when  present. 

It  is  important  to  determine  whether  we  must  deal 
with  the  pediculus  vestimentorum,  the  so-called  body 
louse,  or  with  the  pubic  louse,  as  the  two  species  of 
louse  demand  different  treatment.  The  body  louse  in- 
habits the  clothes  alone,  and  if  we  search  carefully  we 
will  find  either  the  lice  crawling  about  the  clothing  or 
will  see  its  eggs  deposited  in  groups  aloug  the  seams  of 
the  clothing.  The  pubic  louse  dwells  upon  the  hairy 
skin  alone,  and  neither  it  nor  its  egg  is  to  be  found  in 


^S.S  DISEASES  OF  THE   HAIR  AXD   SCALt>. 

the  clothing.  The  scratch  marks  of  pediculosis  vesti- 
mentoruin  are  found  over  the  shoulders  posteriorly, 
ahout  the  waist,  and  along  the  outer  side  of  the  limbs 
where  the  seams  of  the  clothing  come.  The  long 
parallel  scratch  marks  over  the  shoulders  are  pathog- 
nomonic of  this  form  of  lice.  The  scratch  marks  of 
pediculosis  pubis  are  limited  more  to  hairy  parts,  and 
therefore  are  seen  more  commonly  on  the  anterior  face 
of  the  trunk,  and  in  the  axillae.  Maculae  ceruleae  are 
met  with  in  this  form  alone. 

Prognosis. — There  will  be  no  difficulty  in  curing  the 
disease  if  we  have  once  made  the  diagnosis. 

Treatment.— The  quickest  and  neatest  method  of 
treatment,  when  the  patient  A\ill  allow  of  it,  is  to 
shave  the  affected  parts.  By  this  means  we  at  once 
destroy  the  lice,  nor  need  we  wait  until  any  compli- 
cating eczema  is  cured.  One  of  the  most  frequently 
employed  remedies  is  mercurial  ointment.  It  is  effica- 
cious, but  very  often  proves  irritating  and  sets  up  a 
pustular  eczema.  A  lotion  of  the  bichloride  of  mer- 
cury is  better.  If  there  is  much  excoriation  mercurials 
are  to  be  avoided.  Any  of  the  remedies  used  in  pedi- 
culosis capitis  will  be  useful  here,  and  need  not  now 
be  detailed.  Chloroform  may  be  used  to  destroy  the 
lice  where  the  skin  is  uninjured,  using  the  plan  pro- 
posed by  Hamal  (590)  in  1S5T,  namely,  after  washing 
the  part  with  soap  and  water,  and  then  with  clear 
water,  and  drying,  pour  chloroform  on  drop  by  drop  and 
iTib  in.  Then  cover  with  a  folded  handkerchief  for  a 
half  hour,  and  wash  again  to  remove  the  debris  of 
pediculi.  As  the  chloroform  is  irritating  it  is  advisa- 
ble to  protect  the  skin  of  neighboring  parts  w^ith  pow- 
der. Ether  will  act  in  the  same  way  as  the  chloro- 
form. Hot  baths  \^ith  the  free  use  of  soap,  and  sub- 
sequent bathing  with  carbolized  water,  is  a  good  plan 
of  treatment  for  a  generalized  ^pediculosis  caused  by 
the  pubic  louse,  care  being  taken  to  get  rid  of  the  ova. 


t>EDICULOSIS  PUBIS  Et  PALPEBRARUM.  28^ 

Mourson  caused  the  maculae  ceruleae  to  disappear 
promptly  with  a  solution  of  hypochlorite  of  soda. 

Pediculosis  Palpebrarum  is  a  very  rare  form  of 
pediculosis,  which  occurs  most  frequently  in  children. 
It  is  caused  by  the  pubic  louse  and  is  communicated  in 
some  cases  from  the  beard  of  a  man  in  the  act  of 
fondling  a  child.  As  a  rule  there  is  but  little  itching  in 
this  form  of  pediculosis,  though  there  is  enough  to 
cause  the  patient  to  rub  the  eyelids.  The  irritation  by 
the  lice  and  by  the  rubbing  gives  rise  to  redness  of  the 
lids  and  even  eczema.  Usually  the  eyelids  will  be 
found  reddened,  crusted,  and  scaly,  and  sometimes 
some  of  the  eyelashes  are  broken  off.  Close  examina- 
tion will  show  the  lice  either  at  the  roots  of  the  eye- 
lashes in  the  characteristic  position,  or  wandering 
about,  and  the  eyelashes  will  have  ova  upon  them. 
Minute  reddish  specks  of  excrement  are  to  be  seen  on 
the  edge  of  the  lids,  especially  the  lower  one.  One  or 
both  lids  may  be  affected,  and  the  disease  is  symmetri- 
cal or  unilateral.  The  whole  of  a  lid  may  be  diseased, 
or  only  places  here  and  there.  The  eyebrows  may 
also  be  involved  with  the  eyelashes,  or  be  affected  inde- 
pendently of  them. 

The  treatment  consists  either  in  pulling  out  all  dis- 
eased hairs,  and  then  smearing  on  mercurial  ointment, 
which  is  a  rapid  and  radical  plan  of  treatment;  or  the 
mercurial  ointment  may  be  smeared  on,  and  soap  and 
water  used  to  wash  off  the  lice  and  remove  the  ova. 
As  the  first  plan  results  in  a  temporary  deformity,  and 
the  second  is  quite  as  effectual  though  slovv^er,  the 
latter  is  to  be  preferred. 


CHAPTER  XVIII. 

BEIGEL'S  disease,    or  the   CHIGXOX  fungus  ;    PIEDRA  ; 

TRICHOMYCOSIS   NODOSA  ;     AND     OTHER 

PARASITIC    DISEASES. 

Besides  favus,  ringworm,  and  pediculosis,  there 
have  been  described  from  time  to  time  other  parasitic 
diseases  which  involve  the  hair.  In  this  tjhapter  will 
be  found  Beigel's  disease,  Piedra,  Tinea  nodosa,  Tri- 
chomycosis nodosa,  and  some  unclassified  parasitic 
diseases. 


beigel  s  disease. 

In  1S66,  Professor  Lixdemaxn  of  Petersburg  first 
described  a  parasite  that  he  fomid  in  artificial  hair, 
and  which  he  considered  a  species  of  gregarine,  or 
low  form  of  animal  life  on  the  border  line  between 
the  vegetable  and  the  animal  world.  Shortly  after 
this  Beigel  (44)  examined  a  number  of  samples  of  arti- 
ficial hair,  and  in  one,  which  had  been  discarded  by  the 
hair- workers  as  unfit  for  use,  he  found  upon  each  hair  a 
number  of  dirty  brown  knots  which  adhered  very  close- 
ly to  it.  The  hair  itself  was  unaffected,  and  the  knot 
formed  a  sort  of  sheath  to  it.  With  considerable  care  it 
could  be  stripped  off  without  damaging  the  hair.  Micro- 
scopical examination  showed  that  these  knots  were  com- 
posed of  micrococci  in  chains,  and  of  large  round  cells 
containing  two  to  four  large  nuclei.  The  fungus  groTvi^h 
was  pronoimced  by  Kuchexmeister  as  a  new  species 


PIEDRA.  291 

of  pleurococcus.  Hallier  (4:4)  subsequently  deter- 
mined that  they  were  a  new  species  of  Sclerotium,  and 
a  stage  in  the  development  of  the  well-known  peni- 
cillium.  Behrend  (3)  considers  the  chignon  fungus  as 
being  a  species  of  Piedra. 

Beigel  determined  by  experiment  that  the  chignon 
fungus  was  incapable  of  producing  the  slightest  ill 
effect  upon  the  skin.  It  is  therefore  simply  a  scientific 
curiosity. 

PfEDRA. 

The  best  description  of  this  is  given  by  Malcolm  Mor- 
ris (293)  in  his  paper  upon  the  subject  reported  in  the 
Transactions  of  the  Pathological  Society  of  London, 
1879,  vol.  XXX.,  page  441:  also  in  the  Lancet,  1879,  x., 
407.  It  is  upon  this  paper  I  mainly  rely  in  the  follow- 
ing account  of  the  disease,  as  from  its  rarity  I  have 
not  had  an  opportunity  to  study  it. 

Description.— Piedra  is  said  to  occur  only  in  Cauca, 
one  of  the  United  States  of  Colombia,  and  was  first 
described  in  1874  by  Dr.  N.  Osorio  of  the  University 
of  Bogota.  It  consists  in  the  occurrence,  along  the  shaft 
of  the  hair,  of  from  one  to  ten  smaU  dark-colored  nodes 
which  are  very  hard  and  gritty,  and  rattle  like  stones 
when  the  hair  is  combed  or  shaken.  The  stony  hard- 
ness of  the  nodes  gave  the  disease  its  name,  which  in 
the  Spanish  language  means  *' stone."  These  nodes 
are  always  placed  at  irregular  intervals  along  the  hair- 
shaft,  and  are  first  met  with  at  about  half  an  inch 
from  the  point  of  exit  of  the  hair,  the  root  being 
unaffected.  The  disease  occurs  most  frequently  in 
women,  men  being  but  rarely  affected,  and  it  is  the 
scalp-hair  alone  which  exhibits  the  disease.  It  is  non- 
contagious and  seems  to  be  met  with  only  in  warm 
valleys.     The  hair  has  an  acid  odor. 


292  DISEASES   OF   THE   HAIR  AXD   SCALP. 

Etiology.— Dr.  Osorio  thought  that  the  nodes  were 
produced  by  an  agglomeration  of  epithelium  in  certain 
parts  of  the  hair.  Morris  believes  that  it  is  a  fungoid 
gro\\i:h,  and  due  to  the  use  of  a  pecuhar  mucilaginous 
hnseed-hke  oil  by  the  natives,  especially  by  the  women, 
to  keep  the  hair  smooth  and  shiny.  Another  theory 
is,  that  it  depends  upon  the  use  of  the  watei*s  of  certain 
stagnant  rivei-s,  wliich  are  very  mucilaginous.  Heat 
seems  essential  for  its  production,  as  the  use  of  either 
the  oil  or  the  water  fails  to  cause  the  disease  in  cold 
chmates. 

Pathology. — The  hair  is  formd  to  be  dark,  weak, 
and  flaccid.  The  nodes  are  very  hard  to  cut,  and 
when  considerable  force  is  used  they  break.  Under 
the  microscope  the  appearance  is  that  of  a  honey-comb 
mass  consisting  of  spore-hke  bodies,  deeply  pigmented 
on  their  surface.  The  mass  in  its  early  stage  seems  to 
oiiginate  from  one  cell  that  gi^ows  by  budding  in  every 
direction,  forming  radiating  columns  of  spore -like 
bodies.  As  soon  as  the  mass  has  gT0^^^l  to  a  certain 
size,  the  surface  cells  seem  to  alter  in  shape,  become 
darker  in  color,  and  form  a  pseudo-epidermis.  Mor- 
ris, (293). 

Diagnosis. — It  is  differentiated  from  trichoiThexis 
nodosa  by  the  stony  hardness  of  the  nodes,  by  its  oc- 
curring principally  upon  the  scalp-hair,  by  its  probable 
etiology  and  by  the  microscopical  appearances  it  pre- 
sents. 

The  third  nodular  disease  of  the  hair  is 

tinea  nodosa. 

This  name  is  selected  by  Cheadle  and  Morris  (278) 
to  designate  a  condition  of  the  hair  which  differs  from 
trichorrhexis  nodosa,  in  the  presence  of  a  parasitic 
growth  resembling,  though  larger  than,  that  of  tinea 
tonsm-ans;  in  the  marked  incrustation  of  the  hair-shaft 


TINEA   NODOSA— LEPOTHRIX.  293 

by  this  growth;  and  in  the  absence  of  multiform  sym- 
metrical nodosities.  It  also  lacks  the  stony  hardness 
of  Piedra. 

According  to  their  description  the  hair  folhcles  and 
the  skin  were  unaffected,  and  the  hairs  were  firmly 
fixed  in  their  foUicles.  The  affected  hairs  looked  as  if 
incrusted  by  a  granular  material  around  and  external 
to  the  shaft.  In  some  places  sphtting  of  the  hair  and 
incrustation  occurred  together;  in  other  places  incrust- 
ation was  seen  alone,  the  hair- shaft  being  intact  though 
somewhat  cloudy  and  opaque.  The  incrustation  in- 
creases toward  and  reaches  its  maximum  at  the  free 
extremity.  With  high  powers  the  incrustation  was 
seen  to  consist  of  an  agglomeration  of  minute,  spher- 
ical, light-refracting  bodies  of  uniform  size,  and  hav- 
ing all  the  characters  of  a  vegetable  parasite.  The 
sporules  adhered,  as  a  rule,  in  masses  like  fish-roe;  but 
a  few  were  found  scattered  about  in  small  groups.  As 
a  rule  none  were  found  within  the  hair- shaft.  When 
splitting  and  fibrillar  disintegration  were  well  advanced, 
a  few  spore  like  bodies  were  seen  clinging  to  the  fibrils, 
or  more  rarely  lodged  in  the  interstices  between  them. 
The  spores  were  larger  than  those  of  tinea  tonsurans. 

LEPOTHRIX. 

This  disease  was  first  described  by  Paxton  (295),  and 
received  its  name  from  AVilsox.  Patteson  (418,  419 
ap.)  has  studied  it  carefully  and  proposed  for  it  the 
name  of  Trichomycosis  nodosa. 

It  affects  the  hair  of  the  axilla?  and  scrotum,  and 
assumes  two  forms,  a  diffuse  and  a  nodular  form.  In 
the  first  the  hairs  appear  dry  and  dull,  and  look  as  if 
they  had  been  steamed.  Tliey  feel  rough  and  knotted, 
on  account  of  the  projection  from  the  side  of  the 
shafts  of  numerous  minute  concretions.  The  w^hole 
hair  may  be  involved,  or  there  may  be  intervals  of 


29i  DISEASES   OF   THE   HAIK  AND   SCALP. 

sound  hair.  The  nodular  form  consists  of  small, 
rounded  masses,  generally  most  thickly  placed  on  the 
terminal  third  of  the  shaft.  Both  forms  may  be  pre- 
sent on  the  same  hair.  They  are  firmly  adherent,  and 
cannot  be  separated  from  the  hair  without  injury  to 
it.  The  hairs  themselves  are  usually  unaffected  and 
end  with  fine  points.  Occasionally  they  break  through 
a  node  and  their  ends  split  up  into  fine  fibres.  The 
follicles  are  not  implicated. 

The  disease  is  due  to  the  gro\vth  of  bacilli  upon  the 
hairs  of  individuals  who  sweat  freely.  The  sweating 
loosens  the  epidermic  scales  of  hair  and  allows  of  the 
lodgment  of  the  bacilli.  At  first  these  lie  in  small  jDits 
or  depressions  on  the  hair,  but  by  their  growth  they 
break  the  cortical  fibres.  They  also  produce  a  hard, 
homogeneous,  granular  substance,  which  lies  between 
and  around  the  bacteria  and  forms  the  nodes,  at  the 
same  time  acting  like  a  cement  to  prevent  the  break- 
ing of  the  hair.  The  bacilli  are  short,  fine  rods  with 
slightly  rounded  ends,  two  or  three  times  as  long  as 
broad,  and  about  one-fourth  the  diameter  of  a  red 
blood  corpuscle.  They  stain  readily  with  aniline  dyes, 
but  best  by  Gram's  method.  They  are  sometimes 
joined  together,  but  do  not  form  threads.  They  are 
not  cultivatable  by  ordinary  methods. 

It  will  be  seen  that  this  disease  bears  a  close  resem- 
blance to  tinea  nodosa.  Treatment  has  not  been  very 
successful,  but  an  antiparasitic  lotion  is  indicated  and 
the  use  of  soap  and  water. 

DISEASES  OF  THE   HAIR  CONNECTED  ^VITH  EXCESSIVE 

SWEATING. 

Various  colored  nodes  surrounding  tlie  hair  are 
found  in  subjects  who  sweat  profusely.  These  are 
met  with  most  often  in   the   axillae,  then  upon  the 


DISEASES   CONNECTED   WITH  EXCESSIVE   SWEATING.    295 

chest,  genital  regions,  and  inside  of  thighs.  They  are 
of  large  and  small  size,  completely  invest  the  hair 
sometimes  to  a  considerable  length,  and  adhere  closely. 
Behkend  (3)  says  that  they  are  found  in  twenty  per 
cent,  of  all  individuals  in  Germany.  They  certainly  are 
much  less  frequent  in  this  country.  They  occur  most 
often  in  Summer  and  in  those  who  do  not  bathe  fre- 
quently, and,  like  Beigel's  chignon  fungus,  are  of  no 
pathological  significance,  excepting  that  they  may  be 
the  cause  of  chromidrosis  staining  the  underclothing 
red. 

The  color  of  these  nodes  is  grayish,  yellowish  red  or 
brown.  When  the  hair  is  dry  they  are  hard,  and 
appear  under  the  microscope  as  sharply  contoured 
bodies.  When  plucked  from  the  sweating  skin  they 
appear  as  slimy  or  gelatinous  masses.  They  are  com- 
posed entirely  of  micrococci,  of  which  several  different 
forms  have  been  described.  Eberth  (598)  has  met 
with  tliem  in  the  form  of  colonies  composed  of  round, 
oval  and  biscuit-shaped  bacteria;  as  ball-shaped,  some- 
what larger,  bacteria;  and  as  bacteria  in  chains. 

The  sweat  macerates  the  hair  and  loosens  its  cuticle 
in  places.  In  tliese  the  micrococci  gain  lodgment,  and 
their  growth  being  favored  by  the  heat  and  moisture, 
they  rapidly  increase,  still  further  lift  up  the  cuticle, 
and  form  nodes.  It  is  possible  that  they  may  even 
penetrate  between  the  cortical  fibres,  though  Waldeyer 
is  inclined  to  doubt  this. 

Under  the  title  of  "'Dermatojiiykosis  PalmelUna,^'' 
Pick  (000),  in  1875,  described  similar  micrococci  due  to 
sweating  and  occurring  in  the  same  situations.  But  he 
found  in  his  case  that  the  hair  was  fragile,  and  in  places 
broken  off  so  as  to  leave  bald  spots.  Martin  (599), 
in  1862,  reported  a  case  in  which  a  patch  of  hair  on 
the  occiput  of  a  girl  recovering  from  typhoid  fever  be- 
came golden  or  yellowish  red,  and  looked  as  if  smeared 


29G  DISEASES   OF   THE   HAIR  AND   SCALP. 

with  a  yellowish  red  pomade.  In  one  part  of  the 
patch  the  Jiair  had  dropped  out  or  was  broken  off,  and 
in  other  parts  it  looked  as  if  it  had  been  singed.  The 
pomade-like  substance  was  composed  of  epiphytes, 
the  ZoogJea  Cajnlloruui  of  Btihl. 

UNCLASSIFIED   PARASITIC   DISEASES   OF  THE   HAIR. 

DuHRiNG  (597),  in  IS 76,  reported  a  case  of  parasitic 
disease  of  the  hair  of  the  head  in  which  ova  were  found 
upon  the  hau',  and  papules  and  pustules  on  the  scalp. 
Xo  insect  couJd  be  detected  about  the  scalp  or  person, 
and  the  ova,  though  watched  for  some  time,  did  not 
undergo  change.  The  ova  were  firmh^  attached  to  the 
shaft  of  the  hair,  close  to  the  root,  and  were  of  elon- 
gated, elliptical  shape.  One  end  was  glued  to  the  hair, 
the  othei'  terminated  in  a  romided,  somewhat  tapering 
form.  They  were  firm  in  consistence,  half  a  hue  in 
length,  and  a  twelfth  of  a  hne  in  width.  Their  color 
was  straw  yellow.  From  four  to  a  dozen  ova  were 
fastened  to  a  hair,  arranged  in  rows,  close  to  one  an- 
other and  pointing  obhquely  upwards  away  from  the 
•scalp. 

Thin  (601),  in  1882,  reported  a  case  of  parasitic  dis- 
ease of  the  moustache  occurring  in  a  man  of  good 
health,  readily  cured,  but  reappearing  once  a  year  for 
five  yeai^.  It  caused  a  bald  strip  one  quarter  of  an 
inch  l)road,  extending  from  the  upper  to  the  lower 
border  of  the  moustache.  The  diseased  surface  had 
the  characteristic  appearances  of  ringworm.  The  hair 
contained  spores  similar  to  the  trichophyton  fungus, 
but  were  diseased  at  their  free  extremities  first,  instead 
of  at  theii*  roots,  as  is  the  case  in  ringworm. 


PAET  lY. 

DISEASES  OF    THE    HAIR    SECONDARY    TO 
DISEASES  OF  THE  SKIN. 


CHAPTER  XIX. 

DANDRUFF. 

Synonyms: — Seborrhoea  sicca  capitis;  Pityriasis  capi- 
tis; Dandriff  ;  Eczema  seborrhoicum. 

The  term  dandruff  or  dandriff  has  been  used  to  des- 
ignate at  least  four  distinct  diseases  of  the  scalp,  name- 
ly: pityriasis  simplex,  seborrhoea  sicca,  eczema  ery- 
tliematosum  or  squamosum,  and  psoriasis;  and  it  is 
probable  that  a  fifth  disease,  diffuse  trichophytosis 
capitis,  has  been  included  under  it.  Properly  speaking, 
its  use  should  be  limited  to  that  scaly  condition  of  the 
lioad  which  is  due  to  seborrhoea  sicca  or  pityriasis  sim- 
plex— the  seborrhoeal  eczema  of  Unna. 

Whether  these  latter  three  diseases  are  identical  or 
not,  is  still  an  unsettled  question.  By  some  authori- 
t  ies  they  are  regarded  as  one  and  the  same  disease,  but 
t  hey  present  enough  points  of  difference  to  entitle  them 
to  separate  consideration.  I  have  here  placed  them 
together  for  convenience,  as  they  give  rise  to  a  some- 
Avhat  similar  condition  of  the  scalp,  and  are  amenable 
to  the  same  treatment, 

Seborrhoea  sicca  ir.,  as  commonly  taught,  a  functional 
disease  of  the  sebaceous  glands,  in  which  an  abnormal 
amount  of  sebaceous  matter  of  abnormal  consistence 
is  secreted  by  them.  This  dries  upon  the  scalp,  and 
cither  appears  in  the  form  of  thin,  fatty  plates  about 
the  mouths  of  the  hair-follicles,  or  adheres  to  the  hairs 
ill  flakes,  or,  if  very  abundant,  heaps  up  into  thick, 
fatty  masses  or  cakes,  which  cling  with  a  good  deal  of 
tenacity  to  the  scalp.     This  latter  form  is  seen  very 


300  DISEASES  OF  THE  HAIR  AND  SCALP. 

frequently  in  children,  during  the  early  months  of  in- 
fancy, and  is  the  remains  of  the  vernix  caseosa.  If 
portions  of  these  crusts  or  cakes  are  rubbed  between 
the  thumb  and  finger,  they  will  impart  an  unctuous 
feeling.  The  scalp  in  this  disease  is  usually  pale  or 
leaden-hued,  and  when  the  crusts  are  removed  shows 
no  tendency  to  moisture,  or  else  exhibits  a  fatty,  glis- 
tening surface  upon  which  the  crust  is  soon  renewed. 
In  some  cases  more  activity  is  shown,  and  the  scalp 
is  slightly  reddened.  This  affection  runs  a  chronic 
course,  is  generally  most  pronounced  on  the  vertex, 
but  often  is  distributed  quite  uniformly  over  the  whole 
head.  Some  pruritus  at  times  is  present,  and  in  some 
cases,  in  consequence  of  scratching,  there  will  be  ex- 
coriations. Seborrhoea  of  the  scalp  may  also  take  the 
oily  form  (seborrhoea  oleosa),  though  this  is  unusual. 
In  that  case,  instead  of  the  scalp  being  covered  with 
fatty  plates  and  scales,  it  will  be  oily,  a»d  the  hair 
shiny. 

Pityriasis  simplex,  sen  capillitii,  is  essentially  an 
interference  with  the  cornification  of  the  upper  cell- 
layers  of  the  skin,  on  account  of  which,  instead  of  the 
normally  compact  stratum  corneum,  we  have  a  con- 
stant shaling  off  of  imperfectly  formed  epithehal  scales. 
The  whole  scalp  may  be  quite  uniformly  affected,  or 
the  disease  may  be  hmited  to  the  vertex,  or  it  may 
occur  in  circumscribed  patches.  The  scales  are  thin, 
easily  detached  from  the  scalp,  sometimes  so  easily  as 
to  be  readily  blown  off,  and  they  do  not  pile  up  into 
crusts.  When  rubbed  between  the  thumb  and  finger 
these  scales  do  not  impart  the  same  unctuous  feeling 
as  do  those  of  seborrhoea  sicca,  though  there  is  usually 
a  certain  amount  of  sebaceous  matter  present,  just  as 
in  seborrlioea  sicca  there  is  always  an  admixture  of 
epithelial  scales.  Usually  the  scalp  is  of  normal  color, 
though  often  it  is  shghtly  reddened  from  hyperaemia. 


DANDRUFF.  301 

There  is  never  any  moisture  of  the  scalp.  Pruritus 
often  annoys  the  patient,  especially  when  he  is  over- 
heated or  is  using  his  brain  actively,  and  this  inviting 
scratching,  excoriations  are  often  met  with. 

Unna,  of  Hamburg,  and  Elliot,  of  New  York,  to- 
gether with  some  other  authorities,  would  do  away 
with  both  of  the  names  seborrhoea  and  pityriasis,  and 
substitute  that  of  sehorrh(xal  eczema,  as  they  regard 
both  of  the  former  as  but  degrees  of  the  latter,  and 
both  of  them  as  inflammatory  diseases  of  the  scalp. 

These  two  diseases,  differing  mainly  in  their  essen- 
tial lesion  and  constituting  dandruff,  cause  annoyance 
by  the  constant  falling  of  the  scales  upon  the  shoulders 
of  the  patient,  thus  ruining  the  clothing,  or  giving  it 
the  appearance  of  being  powdered;  and  by  the  pruri- 
tus which  attends  them.  The  hair,  too,  is  generally 
dry,  and  will  not  stay  smooth  after  brushing.  It  is 
for  these  reasons,  in  most  cases,  that  the  patients  ap- 
ply to  us  for  relief.  But  dandruff  is  in  many  cases  the 
forerunner  of  baldness,  and  the  fact  that  a  long  con- 
tinued seborrhoea  sicca,  or  pityriasis,  is  the  most  fre- 
quent cause  of  premature  alopecia,  should  stimulate  us 
to  use  our  best  efforts  to  cure  the  disease. 

Etiology. — Dandruff  is  one  of  the  most  common  of 
skin  diseases.  Statistical  tables  would  not  show  this, 
as  it  is  seldom  so  bad  as  to  demand  medical  aid.  It 
frequently  occurs  in  strumous  individuals  who  are 
anaemic  and  have  a  sluggish  circulation  niarked  by 
cold  hands  and  feet.  Adolescence  is  its  peculiar  time 
of  appearance,  and  chlorotic  girls  are  apt  to  be  annoyed 
by  it.  It  is  an  attendant  upon  chronic  debilitating  dis- 
eases, such  as  rheumatism,  syphilis,  phtliisis,  and  the 
like,  and  comes  on  after  profound  disturbances  of  the 
constitution,  such  as  fevers  and  parturition.  Dyspep- 
sia and  constipation  are  very  common  exciting  causes 
or  aggravants  of  the  disease.     Improper  care  of  the 


302  DISEASES   OF  THE   HAIR  AXD  SCALP. 

scalp,  the  use  of  the  fine-toothed  comb,  and  of  pomades, 
hair  "tonics,"  and  hair-dyes,  will  give  rise  to  the  dis- 
order.  In  some  cases  there  is  apparently  no  cause  for 
the  disease,  but  careful  inquiry,  even  in  these  cases, 
will  usually  bring  out  some  latent  cause,  such  as 
worry,  overwork,  mental  or  nervous  strain,  and  the 
like.  Malassez,  Thix,  Chtncholle,  and  some  others, 
claim  to  have  found  a  parasite  as  the  origin  of  the 
trouble;  and  recent  experiments  by  Lassar  and  Bish- 
op would  seem  to  prove  that  the  disease,  at  least  pity- 
riasis simplex,  is  contagious."  The  jDarasitic  and  con- 
tagious theory  of  its  origin  is  gaining  ground. 

Pathology. — Seborrhoea  sicca  is  a  functional  disease 
of  the  sebaceous  glands,  no  structm^al  derangement  of 
them  having  been  found.  The  normal  change  of  the 
hning  cells  of  the  glands  into  oil  globules,  which  escape 
through  the  gland  ducts  as  an  oily  secretion,  is  miper- 
fectly  performed,  and  instead  of  an  oily  fluid  we  have 
an  inspissated  fat.  ^licroscopical  examination  shows 
the  ciiist  of  seboiThoea  sicca  to  be  composed  of  a  gran- 
ular mass  of  epithehal  cells  in  various  stages  of  fatty 
degeneration,  and  some  oil  globules. 

Pityriasis  is  a  consequence  of  imperfect  comification,  a 
condition  that  sometimes  follows  a  squamous  eczema. 
By  some  authorities,  as  is  stated  mider  etiology,  a  par- 
asite is  maintained  to  be  the  reason  of  the  desquama- 
tion. Both  Malassez  (169)  and  Chixcholle  (OOJ:),  in 
lb 74,  described  parasites  found  in  the  scales  from  cases 
of  pityriasis  capitis,  and  asseiied  that  they  were  the 
cause  of  tlie  disease.  They  described  them  as  oval  or 
spherical  in  shape,  and  from  2  to  5  mm.  in  length, 
without  myceha,  and  forming  more  or  less  extended 
sheets  upon  the  surface  of  the  corneous  layer  of  the 


*  The  experiments  of  Lassar  and  Bishop  wiU  be  found  in  Chapter 
VI.,  page  97,  of  this  work. 


DANDRUFF.  303 

Skin,  splitting  it  intolayers:  These  spores  of  Malassp:z 
and  Chincholle  are  probably  identical  with  the  sac- 
charomyces  sphoericus  et  ovalis  of  Bizzozero  (603), 
which  according  to  him  are  found  quite  generally  upon 
the  normal  human  skin.  The  question  of  the  parasitic 
or  non -parasitic  nature  of  pityriasis  capitis  cannot  be 
considered  settled  as  yet. 

Diagnosis. — Before  we  can  intelligently  treat  a  case 
of  scurfiness  of  the  scalp  we  must  arrive  at  a  correct 
diagnosis,  and  must  differentiate  between  dandruff  on 
tlie  one  hand  and  eczema,  psoriasis,  and  diffuse  trich- 
ophytosis capitis  on  the  other. 

Eczema  is  distinguished  by  the  scales  not  being  so 
abundant  nor  so  greasy  as  in  dandruff;  by  their  being 
more  parchment  like,  as  if  formed  rather  of  dried 
serum  than  inspissated  fat,  and  more  adherent  to  the 
scalp;  by  the  disease  not  being  so  diffuse,  but  more  hm- 
ited  to  certain  patches,  or  to  one  side  of  the  head,  and 
implicating  contiguous  non-hairy  parts;  by  the 
greater  amount  of  hyperaemia;  by  the  moisture  which 
is  either  present  or  readily  induced  by  scratching;  by 
its  being  far  more  pruriginous,  and  by  its  history. 
If  thick  crusts  are  present  they  will  usually  be  of  a 
greenish-yellow  color  and  when  removed  will  expose  a 
reddened  oozing  surface.  In  eczema  there  will  usually 
be  a  patch  of  the  disease  behind  the  ears. 

Psoriasis  rarely  occurs  upon  the  scalp  without  be- 
ing found  on  other  parts  of  the  body.  It  occurs  in  the 
form  of  circumscribed,  round,  or  oval,  reddish,  infil- 
trated patches,  which  if  of  large  size  are  seen  to  be 
composed  of  a  number  of  smaller  round  patches  which 
have  joined  together  at  their  edges.  These  patches  are 
covered  with  a  thick  mass  of  gi-ayish  or  white  glisten- 
ing scales  which  are  not  greasy,  and  on  being  removed 
expose  a  number  of  minute  bleeding  points  or  red  dots; 
and  they  do  not  reform  as  quickly  as  those  of  sebor- 


304  DISEASES   OF   THE   IIAIR   AXD   SCALP. 

rhoea.  Tlie  disease  tends  to  form  a  fringe  under  the 
hair  on  the  forehead,  and  sometimes  to  push  its  white, 
ghstening,  scaly  surface  doT\'n  upon  it,  and  often  pre- 
sents a  characteristic  patch  just  in  front  of  the  ear. 

Trichophytosis  capitis  (tinea  tonsurans),  when  oc- 
cuning  as  a  "  ring-worm,^'  should  offer  no  difficulty  in 
diagnosis,  its  circular  shape  and  the  presence  of 
broken  and  gnawed-off  hau's  being  pathognomonic. 
The  diffuse  form  is  rare,  and  is  to  be  diagnosed  by  its 
history  of  gradual  spread  from  numerous  reddish 
points  Or  papules,  l)y  its  scales  not  being  greasy,  by  the 
hair  being  broken  oft'  and  fragile,  and  by  the  micro- 
scopical examination  of  the  hair  and  scales,  which 
will  reveal  the  trichophyton  fungus  in  abimdance. 

Besides  these  three  diseases,  lupus  erythematosus 
may  sometimes  call  for  differentiation.  It  is  rarely 
met  with  upon  the  scalp,  and  then  occui^s  in  the  form 
of  a  sharply  detuied  patch,  with  an  infiltrated  reddened 
base  covered  by  a  thin  adlierent  scale,  which  being 
raised  shows  on  its  under  side  a  number  of  prolong- 
ations, the  sebum  plugs  withdrawn  from  the  folhcles. 
It  causes  loss  of  hair  and  well  -marked  atrophic  changes 
in  the  scalp. 

Treatment. — A  good  deal  in  the  way  of  preventive 
treatment  of  dandruff  can  be  accomphshed  by  the  pro- 
per care  of  the  scalp  and  of  the  general  health.  More 
care  than  is  usual  should  be  bestowed  upon  the  oper- 
ations of  brushing  and  combing  the  hair,  washing  the 
scalp,  and  upon  the  selection  of  the  bi-ush  and  comb.* 
Do  not  wash  the  head  too  much.  I  beheve  that  the 
so-commonly  practised  daily  sousing  of  the  head  in 
water  is  hurtful  to  the  hair  and  scalp,  especially  if  they 
are  not  carefully  and  thoroughly  dried  afterward,  and 

*  Full  dii-ectious  as  to  these  mattei-s  will  be  fouud  iu  Chapter  TTT., 
of  this  work. 


DANDRUFF.  305 

a  little  oil  or  vaseline  nibbed  into  the  scalp.  It  is  not 
the  daily  sousing  which  is  objectionable,  but  the  in- 
sufficient after-care.  Water  renders  the  hair  dry,  and 
the  daily  sousing  only  washes  the  head  superficially. 
A  good  shampoo  every  week  or  ten  days  for  those  per- 
sons exposed  to  a  good  deal  of  dust,  and  every  two  or 
three  weeks  for  other  people,  is  sufficient  for  clean- 
liness. A  shampoo  composed  of  soap  and  water, 
borax  and  water,  or  of  the  yolk  of  an  egg  beaten 
up  in  hme-water,  is  simple  and  good,  but  it  must 
not  be  forgotten  to  wash  out  these  materials  with 
plenty  of  clean  water  and  to  thoroughly  dry  the  hair 
and  scalp. 

Patent  hair  "tonics,"  pomades,  washes,  and  dyes 
are  to  be  avoided.  Those  containing  grease,  the 
pomades,  are,  to  use  an  Anglicism,  "nasty,"  give  the 
hair  an  unnatural  lustre,  smear  the  hat-band  and 
whatever  the  hair  touches,  and,  becoming  rancid,  act  as 
local  irritants.  None  of  these  dressings  are  needed  by 
the  healthy  scalp,  and  the  proper  care  of  the  scalp  as 
above  indicated  wjU  preserve  the  hair  in  better  condition 
than  they  will. 

The  nearer  the  body  can  be  kept  to  the  standard  of 
perfect  health  by  means  of  bathing,  exercise,  and  good 
diet,  the  less  likely  is  dandruff  to  develop.  When, 
therefore,  the  disease  has  appeared,  and  we  are  applied 
to  for  relief,  one  of  our  first  inquiries  should  be  con  - 
cerning  the  general  health,  and  our  first  efforts  ad- 
dressed to  remedying  anything  found  to  be  wrong. 
For,  important  as  our  local  measures  are  in  relieving 
the  local  disorder,  in  most  cases  we  must  depend  upon 
internal  treatment  to  render  the  cure  permanent.  The 
internal  treatment  must  be  along  the  lines  marked  out 
in  works  upon  general  medicine — tonics,  as  cod-liver  oil 
and  iron,  for  the  debilitated;  the  acids  and  bitters  for 


306  DISEASES  OF  THE   HAIR  AXD  SCALP. 

the  neui'otic  and  dyspeptic;  mercurials,  podophylliu, 
and  the  hke  for  the  bihous,  etc.  Duhrixg  (10)  recom- 
mends sulphur  and  the  sulphide  of  calcium  as  of  special 
efficacy;  and  arsenic  sometimes  acts  well.  We  should 
insist  upon  our  patient  obeying  the  laws  of  general 
hygiene  and  instruct  him  as  to  the  proper  care  of  the 
scalp. 

Various  substances,  all  of  a  more  or  less  irritating 
nature,  have  been  recommended  for  the  local  treat- 
ment of  dandruff.  Such  are  tincture  of  cantharides,  3  j. 
to  s  j. ;  tincture  of  capsicmii,  3  j.  to  3  j- ;  tincture  of  nux 
vomica,  3  j.  to  3  j. ;  chloral,  3  j.  to  3  j. ;  bichloride  of  mer- 
cmy,  gr.  ij.  to  iij.  to  3  j. ;  the  oleate  and  other  mercurials 
in  proportionate  strength;  sulphur,  3  j.  to  3  j. ;  carboHc 
acid,  gr.  x.  to  xx.  to  3]'.;  sahcylic  acidgr.  x.  to  xx.  ad 
3  j ;  tar  or  oil  of  cade  3  j.  to  3  iv.  ad  3  j ;  quima,  strychnia, 
etc.  These  are  used  either  in  solution  in  alcohol,  water, 
or  the  oil  of  olive,  castor,  rosemary,  bene,  etc. ;  or  as  oint- 
ments. A  good  menstruum  for  their  exliibition  is  com- 
posed of  glycerine,  3  j.  to  ij.,to  dilute  alcohol,  3  j.  Yase- 
Hne  forms  the  best  medium  for  their  exlnbition  as  oint- 
ments. Excepting  where  the  hair  is  decidedly  thin, 
so  stiff  an  ointment  as  the  ungt.  zinci  oxid.  should  not 
be  used,  and  lard  itself  is  apt  to  become  rancid.  Lano- 
lin is  too  stiff  a  base  unless  very  much  diluted  with 
vaseline  or  oil.  Tlie  tincture  of  benzoin  is  made  a  con- 
stituent of  many  lotions  for  the  scalp,  and  resorcin 
and  icthyol  have  both  been  commended  as  remedies  in 
seborrhoa\  Thus  Fourxier  {^OT)  recommends  the  fol- 
lowing lotion: 

Beef  marrow, 60. 

Oil  of  sweet  alriionds,     ....        20. 

Flower  of  sulphur,  .         .        .        .  1. 

Tinct.  of  benzoin,  ....  6. 

Ihle's  (150)  formula  for  resorcin  is: 


DANDRUFF.  307 

Resorcin,        .        .  .        .         5  to  10. 

Castor  oil,       .        .  ...        45. 

Alcohol, 150. 

Balsam  of  Peru, .5 

Sig.    Daily  rubbed  in  with  a  piece  of  flannel. 
Unna  has  had  good  results  from  icthyol  iii  ointment 
form,  ten  to  twenty  per  cent  strength. 

Heitzmann  (608)  expects  a  rapid  cure  of  his  cases  by 
the  appHcation  to  the  scalf)  of  the  following  ointment: 
Oleum  rusci  .         .         .  3ss=15. 

Ungt.  aquae  rosae  ad   .        .         liv=100. 
01.  rosae         ....        gt.  xtoxx=:l. 
M. 

This  is  to  be  used  at  night,  and  the  superfluity  is  to 
be  rubbed  off  with  a  dry  rag  in  the  morning.  Twice 
a  week  the  head  is  to  be  shampooed  with  castile  soap 
and  water. 

Before  using  any  remedy  for  the  dandruff  the  scalp 
must  be  cleaned.  If  there  is  enough  accumulation  of 
fat  scales  to  form  crusts,  the  head  must  be  saturated 
with  oil,  preferably  sweet  almond  oil,  for  from  twelve 
to  twenty-four  hours,  and  then  washed  with  soap  and 
water.  After  the  hair  and  scalp  have  been  well  dried 
the  chosen  remedy  is  to  be  apphed.  In  shght  cases  of 
dandruff  the  soaking  with  the  oil  may  be  omitted. 

Of  aU  the  above  remedies,  I  have  been  led  by  experi- 
ence to  place  my  main  reliance  upon  sulphur  and  the 
mercurials,  and  would  advise  the  following  plan  of  local 
treatment.  If  the  case  presents  itself  with  a  decided 
accumulation  of  scales,  or  if  crusts  are  present,  direct  the 
patient  to  saturate  his  head  with  oil,  preferably  sweet 
almond  oil,  before  going  to  bed,  and  place  over  his 
head  a  flannel  cloth  soaked  in  the  oil,  and  outside  of 
all  an  oiled  silk  cap.  The  next  morning  he  should 
shampoo   his  head  thoroughly  with  soap  and  water, 


308  DISEASES   OF  THE  HAIli  AND   SCALP. 

using  by  preference  the  tincture  of  green  soap  or  the 
tincture  of  prepared  ohv^e  soap,  and  wash  out  the  soap 
with  plenty  of  water.  The  scalp  is  then  to  be  dried  by 
vigorous  rubbing  with  a  coarse  towel,  and  the  hair  by 
pulling  it  through  a  soft  towel.  If  the  crusts  are  not 
completely  removed  by  this  method,  a  little  oil  should 
be  kept  on  during  the  day,  the  head  soaked  again  at 
night  and  washed  with  soap  and  water  in  the  morn- 
ing. If  the  scalp  should  appear  very  hyperaemic  after 
the  crusts  are  removed,  apply  vaseline  or  simple  oint- 
ment, such  as  rose  ointment,  until  the  hyperaemia  is  les- 
sened. When  the  crusts  are  removed  and  the  hyper- 
aemia  overcome,  have  an  ointment  composed  of  one 
drachm  of  sulphur  loti  to  one  ounce  of  vasehne,  or, 
better, the  sulphur  cream  whose  formula  is  given  under 
Alopecia  furfuracea,  applied  once  a  day  to  the  scalp. 
If  the  scales  form  rapidly,  apply  the  oil  every  night  and 
the  sulphur  ointment  every  morning,  and  wash  the 
head  every  second  or  third  day.  As  soon  as  scaling  is 
lessened  stop  the  use  of  the  oil,  but  continue  the  oint- 
ment, at  first  using  it  every  second  morning,  then 
gradually  reducing  its  apphcation  to  once  a  week. 
Throughout  this  plan  of  treatment  the  head  should  be 
shampooed  about  once  a  week  with  the  tincture  of 
green  soap,  borax  and  water,  or  the  yolks  of  three 
eggs  beaten  up  in  one  pint  of  lime-water,  to  which  a 
half  ounce  of  alcohol  is  added.  Another  excellent 
ointment  for  these  cases,  for  the  formula  of  which  I 
am  indebted  to  Prof.  Bronson,  of  the  New  York  Poly- 
clinic, is  composed  as  follows; 

IJ  Hydrarg.  amnion.,  .        .        .     gr.  xx. 

Hydrarg.  chlor.  mitis,        .        .        .  gr.  xl. 

Petrolati, |j. 

M. 

This  applied  once  or  twice  a  day  has  yielded  most 


DANDRUFF.  309 

admirable  results  in  a  number  of  cases  in  simple  dan- 
diTiff .  Its  consistence  being  that  of  a  Mayonaise  dress- 
ing, renders  it  an  elegant  pomade  for  private  practice. 
Its  use  should  be  combined  with  the  occasional  sham- 
poo, as  directed  above. 

Prognosis. — Dandruff  is  curable,  though  Hable  to 
relapse.  In  some  cases  the  disease  will  disappear  never 
to  come  back;  but  these  are  the  exceptions.  Quite  com- 
monly the  condition  wiU  return  whenever  the  health 
becomes  deteriorated.  We  should  inform  our  patients 
of  this  fact,  and  tell  them  that  they  will  obtain  sl  cure 
only  by  persistent,  long-continued,  and  oft-repeated 
effort. 


CHAPTER  XX. 

KERATOSIS  PILARIS. 

Synonyms. — Lichen  pilaris;  Pityriasis  pilaris;  Icthy- 
osis  seu  hyperkeratosis  foUicularis;  Cacotrophia  folli- 
culorum  (T.  Fox.) 

Keratosis  pilaris,  as  its  name  indicates,  is  a  disorder 
of  cornification.  It  is  characterised  by  a  heaping  up 
of  the  corneous  cells  about  the  mouths  of  the  hah"-f  olh- 
cles  in  the  form  of  small  conical  whitish  or  grayish  ele- 
vations, the  skin  between  them  being  normal  in  color  and 
texture,  though  often  of  a  grayish  or  brownish  shade 
from  lack  of  cleanhness  and  hyperpigmentation.  It  is 
met  with  principally  upon  the  extensor  surfaces  of  the 
hmbs,  the  upper  arm  and  thigh  being  most  often  affect- 
ed, though  it  may  occur  almost  anywhere  on  the  body 
and  not  infrequently  on  the  scalp.  To  the  eye,  the 
skin  has  the  appearance  of  what  is  commonly  called 
goose  flesh,  ^"  cutis  anserina.^^  It  is  seen  to  be  dotted 
aU  over  with  httle  pinhead  to  small  pea-sized,  conical, 
whitish,  grayish,  blackish,  or  pinkish  papules,  each  of 
which  is  either  pierced  by  a  hair  or  has  at  its  summit 
a  small  black  dot,  indicating  the  mouth  of  a  hair- 
foUicle.  These  papules  are  often  scaly,  sometimes 
surmoimted  by  a  scale.  Sometimes  the  hairs  gi'ow 
vigorously  from  the  papules,  sometimes  they  are 
broken  off,  and  sometimes  are  to  be  found  only  by 
opening  the  papule,  when  they  will  be  seen  cmied  up 
inside  of  it.  To  the  touch  the  skin  feels  dry,  and  harsh 
and  somewhat  like  a  fine  nutmeg  grater. 

Subjective  symptoms  are  wanting  in  most  cases,  but 
there  often  is  more  or  less  prmitus,  especially  in  chil- 


KERATOSIS   PILARIS.  311 

dren;  and  in  them  tliere  may  be  a  slight  degree  of  ec- 
zema on  account  of  the  scratching.  Occurring  on  the 
scalp  it  sometimes  produces  baldness. 

Etiology. — The  disease  is  most  often  met  with  after 
puberty,  though  it  may  be  congenital.  It  is  a  very 
common  affection  of  the  skin,  but,  as  it  gives  little  or 
no  trouble,  we  are  seldom  called  upon  to  treat  it.  It 
is  the  result  of  an  inactive  state  of  the  skin,  and  is 
seen  most  often  in  those  who  do  not  bathe  with  suffi- 
cient frequence.  It  is  met  with  in  connection  with 
icthyosis  and  prurigo,  and  is  said  to  follow  pityriasis 
rubra.  It  was  formerly  regarded  as  a  species  of  papu- 
lar eczema. 

Pathology. — It  is  simply  an  anomaly  of  cornifica- 
tion,  a  thickening  of  the  corneous  layer  of  the  skin 
about  the  mouths  of  the  hair-follicles,  by  which  the 
epithelial  ceUs  are  heaped  up  into  conical  papules.  It 
has  nothing  to  do  with  any  disorder  of  the  sebaceous 
glands  or  of  the  hair-follicle  itself.  When  this  condition 
is  congenital  and  constant  in  spite  of  treatment  it  has 
l)een  named  icthyosis  follicularis,  and  corresponds  to 
T.  Fox's  cacotrophia  folliculorum. 

Diagnosis. — It  is  necessary  for  us  to  differentiate 
keratosis  pilaris  from  cutis  anserina;  the  miliary  papu- 
lar syphilide;  lichen  scrofulosus;  papular  eczema; 
lichen  planus,  and  icthyosis. 

Cutis  anserina  is  a  passing  condition  of  the  skin  in 
which  the  arrectores  pill  muscles  contract  imder  the 
stimulus  of  cold,  and  raise  up  the  hair  and  immediately 
contiguous  parts  into  papules.  Keratosis  pilaris  is 
constant  and  uninfluenced  by  temperature. 

The  miliary  papular  syphilide  has  its  papules 
grouped;  they  are  of  a  dark  red  or  raw  ham  color,  and 
deep  seated,  and  are  only  slightly  scaly.  The  syphilitic 
eruption  is  more  apt  to  be  a  general  one,  and  fades 
away  of  itself  in  a  few  weeks.  The  papules  of  kera- 
tosis are  whitish,  gTayish  or   blackish,  supeificial  so 


312  DISEASES  OF  THE   HAIR  AND   SCALP. 

that  they  are  readily  removable  by  soap  and  water, 
scaly,  and  usually  confined  to  the  arms  and  thighs.  It 
does  not  tend  to  get  well  of  itself. 

Lichen  scrofulosus,  as  generally  seen,  is  in  the  form 
of  well-marked  circular  or  crescentic  patches  of  yellow- 
ish-brown papules  upon  the  trunk,  usually  upon  the 
abdomen.  The  papules  are  shghtly  scaly,  and  the  sub- 
jects generally  present  other  symptoms  of  struma. 
Keratosis  pilaris  does  not  have  grouped  papules;  its  pap- 
ules are  whitish  or  grayish,  and  its  subjects  are  not 
necessarily  strumous. 

Papular  eczema  occurs  as  an  eruption  of  bright  red 
inflammatory  papules  which  tend  to  run  together  and 
form  patches.  It  is  very  itchy,  and  shows  no  predilec- 
tion for  the  upper  arm  and  thigh. 

Lichen  planus  occurs  especially  on  the  anterior  face 
of  the  wrists  as  a  group  of  duU  red  or  Ulac  tinted,  an- 
gular, shghtly  umbilicated,  flat  papules,  and  is  attended 
with  a  good  deal  of  pruritus. 

Icthyosis  is  a  congenital  affection  of  the  general  in- 
tegument, though  most  marked  upon  the  arms  and 
legs.  The  skin  is  dry  and  scaly,  and  marked  off  into 
polygonal  spaces,  and  the  disease  is  incurable.  Kera- 
tosis pilaris  rarely  occurs  before  puberty,  is  limited  to 
the  mouths  of  the  lanugo  hak-follicles,  and  is  perfect- 
ly curable. 

Treatment. — The  vigorous  use  of  soap  and  water 
in  an  alkaline  bath  will  promptly  remove  the  papules. 
The  best  soap  for  the  purpose  is  the  sapo  viridis  or 
soft  soap,  and  this  may  be  used  in  the  form  of  a  tinc- 
ture. 

'  A  vapor  or  Russian  bath  may  be  used  for  the  same 
purpose.  After  the  bath  the  skin  should  be  anointed 
with  oil,  vaseline,  lanohn,  or  any  emollient.  In  some 
obstinate  cases  it  may  be  necessary  to  use  a  mercurial 
such  as: 


KERATOSIS   PILARIS.  313 

^  Hydrarg.  ammon.         .  .         .        3  j— ii 

Hydrarg.  chlor.  mitis,  .         .         .  3ij — iv 

Vaseline,      .         ad    .  .        .        .      5j 
M. 

In  congenital  cases  cod-liver  oil  should  be  given  by 
the  mouth  and  also  rubbed  into  the  affected  skin. 

Prognosis. — The  disease  is  perfectly  and  easily  cur- 
able, but  without  treatment  it  may  last  indefinitely. 
It  is  subject  to  relapses. 


CHAPTER  XXL 

ECZEMA  CAPITIS  ET  B.ARB^. 

The  hairy  parts  of  the  body  are  affected  with  eczema 
eithei*  in  connection  with  or  independently  of  eczema 
of  other  regions.  Owing  to  the  presence  of  the  hair, 
and,  in  some  places,  as  the  scalp,  to  a  difference  in  the 
structure  of  the  under-lying  tissues,  the  disease  in 
hairy  regions  has  some  pecuhar  symptoms.  We  will 
describe  eczema  of  the  scalp,  of  the  bearded  portions 
of  the  face,  and  of  the  edges  of  the  eyehds.  The 
symptoms  of  the  disease,  as  met  with  in  these  regions, 
include  all  that  are  to  be  encountered  in  any  hairy 
region. 

eczema  capitis. 

Synonyms: — Crusta  lactea;  Impetigo  figurata,  seu 
lactantia,  seu  mucosa,  seu  muciflaa;  Porrigo;  Tinea 
amiantacea,  seu  furfuracea,  seu  granulata,  seu  asbes- 
tina;  Melitagra;  Achor;  Eczema  capiUitii;  Erythema 
ichorosum;  Gourme  (Fr.);  Vesicular  or  running  scall, 
scalled  head,  milk  crust  (Eng). 

Symptoms.  —By  the  above  and  a  number  of  other 
names  this  very  common  disease  of  the  hairy  scalp 
has  been  designated.  The  vesicular,  pustular  and 
erythematous  varieties  of  eczema  occur  upon  the  scalp 
as  primary  forms  far  more  frequently  than  the  papu- 
lar variety,  which  is  exceedingly  rare:  squamous  ec- 
zema is  met  with  as  a  sequella  of  the  other  forms. 
Eczema  may  affect  the  whole  scalp  or  only  a  portion 
of  it;  and  it  may  run  an  acute  or  chronic  course.     It 


ECZEMA   CAPITIS  ET  BARB^.  315 

may  occur  either  in  connection  with  eczema  of  other 
parts  of  the  body,  or  independently. 

Vesicular  Eczema. — Eczema  vesiculosum  is  an 
acute  disease  which  breaks  out  either  upon  a  part  or 
the  whole  of  the  scalp.  The  vesicles  are  so  short  lived 
that  the  physician  hardly  ever  sees  them  excepting 
upon  newly  formed  patches.  When  the  case  presents 
itself,  the  scalp  is  seen  to  be  swollen,  at  times  so  much 
so  as  to  give  a  boggy  sensation  to  the  touch;  it  is 
moist,  and  in  bad  cases  exuding  so  freely  that  it  is 
covered  with  a  sticky,  yellowish,  mucilaginous  fluid. 
The  hair  is  always  stuck  together  in  little  bundles,  and 
if  it  is  long  it  will  be  matted.  The  head  emits  a  sick- 
ening odor.  The  exudation  dries  into  light -yellow  ad- 
herent crusts;  when  these  are  removed  a  moist  exud- 
ing surface  is  exposed  that  soon  becomes  again  crusted. 
This  form  of  eczema  may  change  into  the  pustular 
form,  or  it  may  become  squamous.  It  runs  an  acute 
course  in  most  cases. 

Pustular  Eczema.— FiCzema.  pustulosum  occurs  as  an 
eruption  of  discrete  pustules  affecting  a  part  or  the 
whole  of  the  scalp.  The  pustules  soon  become  con- 
fluent, break  down  and  discharge  their  purulent  con- 
tents. The  hair  is  matted  together.  The  exudation 
dries  into  thick  yellowish  green  or  blackish  adherent 
crusts  and  the  head  emits  a  foul  odor.  When  the 
crusts  are  removed  a  moist  exuding  surface  is  left, 
which  soon  becomes  covered  with  a  fresh  crust.  After 
lasting  an  indefinite  time  the  pustular  form  is  ex- 
changed for  the  squamous. 

The  pustular  form  differs  from  the  vesicular  form 
in  having  pustules  rather  than  vesicles;  in  the  char- 
acter of  the  exudate;  in  its  crusts  being  darker  colored; 
and  in  having  a  more  disgusting  odor.  Sometimes 
the  pustules  are  located  only  about  the  hair- follicles 
and  the  disease  will  assume  the  form  of  sycosis.     At 


316  DISEASES   OF   THE   HAIR   AND   SCALP. 

times  there  T^ill  be  marked  swelling  of  the  cervical 
glands;  and,  especially  in  children,  abscesses  of  the 
scalp  may  form. 

Erythematous  E'cze  ???«.— Eczema  erythematosum 
usually  occurs  in  patches  upon  one  side  of  the  head 
but  may  affect  the  whole  scalp.  The  patches  are  of 
irregular  form,  bright  red  in  color,  perfectly  dry  and 
slightly  scaly.  Sometimes  the  skin  may  be  a  little  swol- 
len or  thickened.  If  the  scales  are  removed  with  soap 
and  water  or  slight  friction,  the  skin  will  become  moist 
and  exude  serum  from  innumerable  pores.  This  form 
of  eczema  either  gets  well  rapidly  or  changes  to  the 
squamous  form. 

Squamous  Eczema.  —  Eczema  squamosum  on  the 
scalp  as  elsewhere  is  the  final  stage  through  which  the 
other  varieties  of  eczema  pass  on  their  way  to  recovery. 
The  whole  scalp  may  be  affected  or  only  a  patch  here 
and  there,  depending  upon  the  nature  and  location  of 
the  preceding  primary  form.  It  also  presents  several 
forms.  It  may  be  of  only  slight  intensity  when  the 
scalp  will  be  but  slightly  thickened,  of  light-red  color, 
and  covered  with  whitish  or  grayish  scales,  which  come 
off  readily  in  the  form  of  flakes.  Or  it  may  be  more 
severe,  when  the  scalp  will  be  decidedly  thickened,  of 
deep -red  color,  and  covered  with  more  or  less  adherent 
white  or  gray  scales  in  the  form  of  plates.  Or  the 
thickening  of  the  skin  and  the  inflammation  may  be 
yet  more  severe,  and  the  scalp  will  be  red,  scaly  and 
cracked.  This  form  of  eczema  may  last  indefinitely 
as  a  chronic  eczema  of  the  scalp. 

These  are  the  four  varieties  of  eczema  as  commonly 
met  with  on  the  scalp.  The  pustular  and  the  squa- 
mous forms  are  the  most  frequent,  the  former  especially 
in  children,  where  it  constitutes  the  "milk  crust." 
The  erythematous  form  is  seen  chiefly  in  adults.  At 
times  there  wiU  be  several  varieties  of  eczema  upon  the 


ECZEMA  CAPITIS  ET  BARB^.  317 

scalp  at  once— for  example,  the  pustular  variety  in  one 
place  and  the  squamous  in  another.  With  eczema  of 
the  scalp  we  usually  will  find  a  patch  of  the  same 
disease  behind  or  upon  the  ears,  upon  the  back  of  the 
neck,  or  on  the  face.  Sometimes  other  hairy  regions 
will  be  affected  at  the  same  time,  as  the  pubes  or  axilla. 

The  hair  is  unaffected  as  a  rule,  excepting  that  it  is 
glued  together  by  the  serous  or  sero-purulent  exuda- 
tion of  the  vesicular  and  pustular  forms,  and  is  dry  in 
the  erythematous  and  squamous  forms.  It  is  only 
when  the  disease  is  very  chronic  that  there  is  baldness, 
wiiich  is  not  permanent;  the  hair  in  most  all  cases 
growing  again  when  the  eczema  is  cured.  It  is  not 
uncommon  to  meet  with  baldness  on  the  back  of  the 
head  in  children  with  eczema,  the  hair  being  rubbed 
off  by  the  constant  scratching  of  the  head  against  the 
pillow  or  the  nurse's  arm. 

Itching  is  present  in  gi^eater  or  less  degree  in  all 
cases.  It  is  often  intense  in  the  erythematous  and 
squamous  varieties;  less  marked  in  the  pustular  and 
vesicular  forms.  In  the  acute  stages  of  the  disease 
the  scalp  will  feel  drawn,  and,  may  be,  painful,  and 
there  will  be  more  or  less  of  a  burning  sensation. 

The  sebaceous  glands  are  usually  functionally 
diseased  in  a  case  of  eczema  giving  rise  to  a  seborrhoea. 
In  the  crusts  of  eczema  of  the  scalp  oil  globules  are 
generally  found,  and  in  a  chronic  eczema  the  dry 
and  lustreless  appearance  of  the  hair  is  in  part  due  to  a 
deficiency  of  the  oily  secretion  of  the  sebaceous  glands. 

In  neglected  cases  among  people  who  are  unclean  in 
their  habits  pediculi  find  lodgment  in  the  hair;  and  in 
some  aggravated  cases  of  uncleanliness  we  have  devel- 
oped that  condition  which  is  described  in  the  next 
chapter  as  Plica  Polonica. 

Etiology.— The  etiology  of  eczema  of  the  scalp  is  no 
more  settled  than  is  the  etiology  of  eczema  in  general. 
Some  authorities,  as  in  the  Vienna  school,  insist  upon 


318  DISEASES   OF   THE   HAIR  AND  SCALP. 

the  disease  being  local  in  all  cases  ;  some  of  the  French 
school  are  equally  positive  that  eczema  is  an  expres- 
sion of  a  diathesis;  while  some,  and  perhaps  these  now 
are  in  the  majority,  take  the  safer  middle  course  and 
teach  that  some  cases  are  due  to  local  causes,  and  some 
to  constitutional  conditions.  By  the  use  of  croton  oil 
an  artificial  eczema  can  be  produced  on  any  skin;  but 
that  does  not  prove  that  eczema  is  always  due  to  a 
local  cause.  Water,  with  or  without  strong  alkalies, 
may  be  used  by  a  person  for  years  with  impunity;  then 
there  may  come  a  time  when  it  will  cause  an  intense 
eczema  of  the  hands.  This  seems  to  show  clearly  that 
there  has  arisen  in  the  person  some  constitutional  con- 
dition which  renders  the  skin  obnoxious  to  the  use  of 
water.  Eczema,  I  believe,  may  be  in  some  few  cases 
a  purely  local  disease;  then  it  has  rather  the  nature  of 
a  dermatitis  and  is  of  short  duration.  In  most  cases, 
however,  there  exists  a  predisposition  to  the  disease, 
and  when  the  predisposing  causes  -are  very  pronounced 
and  not  easily  removable,  the  disease  will  be  very 
chronic  and  obstinate  to  treatment.  This  predisposi- 
tion may  be  so  pronounced  that  we  may  speak  of  the 
person  having  it  as  being  eczematous,  just  as  we  would 
speak  of  another  being  rheumatic  or  gouty. 

The  causes  of  eczema  of  the  scalp  are  predisposing 
and  exciting.  Here  I  do  not  intend  to  enter  upon  a 
discussion  of  all  the  causes  of  eczema  as  given  by  dif- 
ferent authors,  but  shall  content  myself  by  giving  such 
as  have  special  relation  to  eczema  of  the  scalp. 

The  predisposing  causes  of  eczema  capitis  are  in- 
fancy and  a  debilitated  condition  of  the  s^^stem  arising 
from  any  cause. 

Age  is  an  important  element  in  etiology.  Children 
under  five  years  of  age  furnish  nearly  one-quarter  of 
all  cases  of  eczema,  -  and  in  them  the  scalp  is  more  fre- 

*Bulkley's  Eczema  and  its  Treatment,  New  York,  1884 


ECZEMA   CAPrnS   ET  BARB^.  319 

quently  attacked  both  independently  and  in  connection 
with  the  disease  elsewhere,  than  is  the  case  in  adults. 
In  forty-nine  personal  cases  of  eczema  of  the  scalp, 
thirty-five  occurred  in  children  under  five  years  of  age, 
and  of  these  twenty-seven  were  in  connection  with  ec 
zema  on  other  parts  of  the  body,  mostly  of  the  ears  and 
face.  In  the  remaining  fourteen  cases  wliich  occurred 
in  adults  six  were  on  the  head  alone.  That  children 
should  be  more  predisposed  to  eczema  than  are  adults 
is  due  to  their  skin  being  more  delicate  and  hence  more 
vulnerable.  In  them,  too,  we  more  often  see  evidences 
of  struma,  and  vices  of  constitution  either  inherited  or 
acquired. 

A  debilitated  condition  of  the  system  predisposes  to 
eczema  in  general,  and  hence  to  eczema  of  the  head. 
Fat  anaemic  babies  are  prone  to  eczema.  Over-fed  or 
under-fed  children,  who  live  in  bad  hygienic  surround- 
ings and  are  uncared  for,  furnish  some  of  our  most  ob 
stinate  cases.  Disturbances  of  the  digestion,  expressed 
either  as  nausea,  vomiting,  diarrhoea,  constipation,  or 
simply  as  malassimilation  without  any  tangible  symp- 
tom, by  their  effect  upon  the  constitution  of  the  blood, 
and  hence  on  the  nutrition  of  the  skin,  predispose  to 
eczema.  Gout  and  rheumatism,  nervous  exhaustion, 
the  chlorotic  state,  predispose  to  the  disease.  In  al- 
most every  case  there  will  be  found  some  deviation 
from  the  standard  of  health. 

The  exciting  causes  of  eczema  capitis  are  all  injuries 
to  or  irritations  of  the  scalp.  In  children  a  very  fre- 
quent exciting  cause  is  well  meant,  but  badly  directed 
efforts  at  cleanliness.  The  vernix  caseosa  is  attacked 
too  vigorously  with  soap  and  water  before  it  is  prop- 
erly soaked  with  oil;  the  fine-toothed  comb  is  em- 
ployed for  the  removal  of  dandruff  and  the  scalp  is 
scratched  by  it;  or  a  too  stiff  bmsh  is  used  for  the  ten- 
der scalp.     In  both  children  and  adults  all  cutaneous 


S20  DISEASES   OF   THE   HAIR  AND   SCALP. 

irritants  may  give  rise  to  eczema,  such  as  mercurial 
ointments  applied  for  the  destruction  of  lice,  and  the 
like;  tincture  of  arnica  for  hruises;  water  fomentations; 
too  strong  applications  for  the  cure  of  sehorrhoea  or 
loss  of  hair,  and  the  like.  Pedicuh  are  very  frequently 
the  cause  of  eczema,  especially  of  the  occipital  region. 
The  too  vigorous  use  of  the  comh  and  hrush  may  act 
like  any  other  irritant  in  causing  the  disease.  It  is  also 
possible  that  in  an  infant  the  growing  hair  may  irri 
tate  the  scalp. 

Diagnosis. — A  moist  eczema  of  the  scalp  is  easy  of 
diagnosis  if  we  remember  that  in  it  the  scalp  is  red- 
dened; more  or  less  thickened;  exuding  in  some  places 
and  crusted  in  others;  itchy;  and  the  hair  is  stuck  to- 
gether as  if  by  mucilage.  Only  one  other  disease  sim- 
ulates it  and  that  is  pediculosis.  On  the  other  hand 
the  erythematous  and  squamous  forms  are  at  times 
difficult  of  diagnosis  froin  pityriasis,  ringworm,  ery- 
sipelas, lupus  erythematosus,  or  a  simple  dermatitis; 
and  pustular  eczema  of  the  scalp  in  its  more  chronic 
form  when  it  occurs  in  patches  may  be  mistaken  for 
psoriasis,  sehorrhoea  sicca,  favus,  or  syphihs. 

A  moist,  exuding  eczema  is  to  be  differentiated  from 
pediciilosishy  its  occurrence  generally  all  over  the  scalp, 
while  pediculosis  is  more  limited  to  the  occipital  and 
temporal  regions.  In  eczema  there  are  no  pediculi 
or  ova,  while  iu  pediculosis  they  are  readily  to  be 
found.  When  pediculosis  is  well  marked  there  is  al- 
ways a  pustular  eczema,  and  in  a  pustular  eczema  of 
any  continuance  there  are  liable  to  be  pediculi.  But 
then  the  diagnosis  is  not  essential,  the  indication  for 
parasiticides  being  so  plain,  that  in  treatment  they  are 
to  be  used  first,  and  afterw^ards  remedies  for  the  ec- 
zema. 

li\  pityriasis  the  scalp  is  but  slightly  reddened,  not 
at  aU  thickened,  the  scales  are  abundant,  readily  de- 


ECZEMA   CAPITIS   ET   BAKB^.  c2l 

tached  and  furfuraceous,  the  hairs  are  not  stuck  to- 
gether, but  frequently  are  found  piercing  a  small  scale. 
In  eczema  the  scalp  is  decidedly  red  and  more  or  less 
thickened;  the  scales  are  moderate  in  amount,  often 
quite  adherent,  and  come  off  in  the  form  of  plates;  and 
the  hairs  here  and  there  may  be  found  stuck  together, 
if  there  are  any  moist  spots  on  the  head. 

Ringworm  occurs  in  one  or  more  circumscribed, 
round,  scaly  patches.  The  patches  of  eczema  are  not 
sharply  circumscribed.  In  ringworm  the  hairs  are 
brittle,  broken  off,  twisted,  and  come  out  readily. 
In  eczema  the  hairs  are  merely  stuck  together.  In 
ringworm  we  have  stumps  of  broken  hair,  which  are 
pathognomonic  of  the  disease.  The  crusts  of  ring- 
worm are  grayish  in  color,  those  of  eczema  are  yellow- 
ish or  greenish.  Eingworm  is  never  moist,  has  a  well- 
marked  history  of  contagion,  the  patches  spread  from 
one  point  peripherally,  and  it  is  not  very  itchy.  Ec- 
zema is  generally  moist  at  some  time,  is  not  contagious, 
does  not  develop  from  one  focus,  and  is  very  itchy. 
In  ringworm  the  trichophyton  fungus  is  readily  de- 
monstrable by  the  microscope.  In  eczema  there  is  no 
fungus. 

Erysipelas  creeps  over  the  scalp  w^ith  a  sharply  cut 
advancing  outline;  there  is  a  considerable  swelling  of 
the  integument,  and  marked  fever  and  cc^nstitufional 
disturbance.  It  runs  its  course  rapidly.  Eczema  has 
an  ill-defined  border,  less  swelhng  of  the  scalp,  and 
sHght  if  any  constitutional  disturbance. 

Lupus  erythematosus  develops  slowly  in  the  form  of 
a  dry,  sharply  defined,  scaly,  red  patch.  In  a  short  time 
there  will  be  loss  of  hair,  and  marked  cicatrisation  in 
the  old  parts  of  the  patch.  The  scales  are  adherent 
and  in  close  relation  to  the  sebaceous  glands.  In  ec- 
zema the  patches  are  »ot  sharply  defined,  there  is  no 
cicatrisation  nor  baldness,  and  the  scales  bear  no  rela- 


oi'2  DISEASES   OF   THE   HAIR   AND   SCALP. 

tion  to  the  sebaceous  glands.  Lupus  is  far  more 
chronic  than  is  eczema,  and  less  amenable  to  treatment. 

A  simple  dermatitis  is  an  acute  redness  and  swelling 
of  the  skin,  arising  from  some  readily  ascertainable 
cause,  and  soon  passes  away.  Should  it  continue  for  a 
few  days  it  will  pass  over  into  an  eczema  with  the 
characteristics  of  the  latter  disease. 

Impetigo  is  regarded  by  many  authorities  as  merely 
a  pustular  eczema,  but  there  is  at  times  an  eruption  of 
discrete  pustules  upon  the  head,  which  show  no  ten- 
dency to  form  patches,  being  isolated  throughout  their 
course.  To  this  eruption  the  name  of  impetigo  is 
given.  It  is  less  itchy  than  is  eczema  and  the  pustules 
are  larger. 

Psoriasis  never  occurs  upon  the  scalp  alone;  char- 
acteristic patches  will  always  be  found  elsewhere  upon 
the  trunk  or  extremities,  and  often  there  is  a  line  of 
scahng  papules  on  the  forehead  along  the  edge  of  the 
hair.  Eczema  is  often  hmited  to  the  scalp,  with  at  most 
a  patch  of  disease  behind  the  ear.  Psoriasis  is  dry  and 
occurs  as  circumscribed,  rounded,  discrete,  small 
patches,  or  larger  ones  evidently  made  up  of  separate 
smaller  ones,  and  covered  with  thick  whitish  or  dirty 
grayish  crusts  composed  of  heaped- up  epidermic  scales. 
When  the  crusts  are  removed  the  under-lying  skin  is 
dry  or  shghtly  moist,  with  a  few  minute  bleeding 
points.  The  patches  of  eczema  are  larger,  and  less  well 
defined;  its  ciiists  are  made  up  of  scales,  dried  pus  and 
sebaceous  matter,  matting  the  hairs  together,  and  when 
they  are  removed  a  moist  exuding  surface  is  exposed. 
Psoriasis  is  less  itchy,  and  there  is  in  it  a  well-marked 
history  of  relapses. 

Sehorrhcea  sicca  affects  by  preference  the  vertex; 
eczema  has  no  sites  of  preference.  In  seborrhoea  the 
scalp  is  normal  in  color  or  pale,  in  eczema  it  is  always 
red.     The  scales  and  crusts  of  sebon-hoea  are  greasy 


ECZEMA   CAPITIS   ET  BARB^.  323 

to  the  touch,  and  gray  or  yellow  in  color;  those  of  ec- 
zema are  harder,  and  yellowish  green  or  even  black. 
Seborrhoea  is  a  dry  disease,  eczema  is  a  moist  one. 
Seborrhoea  is  less  itchy  than  is  eczema,  and  in  it  the 
hair  is  dry  and,  may  be,  powdery,  while  in  eczema  it  is 
stuck  together.  Seborrhoea  is  followed  frequently  by 
permanent  baldness.  Alopecia  may  follow  eczema 
but  in  most  all  cases  it  is  transient. 

Favus  has  yellowy  cupped  crusts  which  are  never  met 
with  in  eczema.  Favus  has  a  history  of  contagion, 
and  of  spreading  from  one  or  two  foci;  causes  bald 
atrophic  patches  of  a  peculiar  red  color;  is  dry  through- 
out its  course;  only  shghtly  itchy;  and  has  a  stale 
straw  or  mousey  odor.  Eczema  has  no  history  of  con- 
tagion; forms  rapidly  into  moist  patches;  is  exceed- 
ingly itchy;  does  not  cause  atrophy  of  the  scalp  nor 
baldness;  and  has  a  sickening  odor. 

Syphilis  differs  from  eczema  in  its  whole  history  and 
course.  Its  pustules  and  papules  are  discrete  and  unat- 
tended by  itching.  Its  pustules  tend  to  break  down  and 
ulcerate,  and  then  are  covered  with  striated  crusts, 
which  being  removed  expose  circular  deep  ulcers, 
which  heal  and  leave  scars.  Nothing  like  this  is  met 
with  in  eczema. 

Treatment.  —  Constitutional  Treatment.  —  The 
treatment  of  eczema  capitis  is  both  constitutional  and  lo- 
cal. Excepting  where  there  is  some  evident  local  cause, 
such  as  the  presence  of  pediculi  or  the  use  of  some  irritat- 
ing application  to  the  scalp,  it  is  necessary  to  enquire 
very  carefully  as  to  the  action  of  the  various  organs  of 
the  patient,  and  to  use  our  best  endeavors  to  aid  them  in 
properly  performing  their  several  functions.  We  must 
regard  the  patient  as  a  sick  man  quite  apart  from  his 
sick  skin.  There  is  no  specific  for  eczema;  each  case 
must  be  treated  on  its  own  merits  according  to  the 
principles  of  general  medicine.     Arsenic  is  one  drug 


324:  DISEASES   OF   THE   HAIR  AND   SCALP. 

that  is  commonly  administered  in  a  routine  way.  In 
most  cases  it  wiU  do  no  good;  in  some  cases  it  will  do 
harm;  and  in  a  very  few  cases  it  will  render  excel- 
lent service.  It  should  be  kept  as  a  last  resort.  The 
acetate  of  potash  is  another  drug  that  is  used  in  a  rou- 
tine way.  It  may  do  good;  it  probably  wiU  do  no 
harm.  I  have  seen  but  little  if  any  benefit  from  its 
use  in  this  affection,  excepting  where  there  is  a  rheu- 
matic or  gouty  condition.  Tonics,  such  as  iron, 
strychnine  and  cod-liver  oil,  are  of  great  service  in  de- 
bilitated, neurotic,  and  aucemic  subjects,  and  will  often 
aid  us  materially,  especially  in  infants  and  children. 

The  care  of  the  digestive  and  aUied  processes  is  all 
important.  If  we  question  mothers  with  eczematous 
babies  we  wiU  find  in  most  cases  that  the  cliildren  are 
nursed  every  time  they  cry,  and  consequently  at  most 
iiTegular  hours;  or  they  are  improperly  fed  either  as 
to  quantity,  quahty,  or  frequency,  being  allowed  to 
eat  "  aoything  that  is  on  the  table,"  besides  numerous 
apples,  bananas  and  cakes  between  meals,  and  to 
drink  beer,  coffee,  tea  and  the  like.  In  adults  we  wiU 
find  quite  as  frequently  great  indiscretions  in  eating 
and  drinking.  Now  this  is  all  wrong.  We  must  in- 
sist upon  an  infant  being  fed  at  regular  intervals  and 
with  the  food  proper  to  its  age.  We  should  inquire  as 
to  the  quantity  and  quaUty  of  the  breast  milk,  and  the 
health  of  the  mother.  Children  should  not  be  allowed 
to  eat  "  what  is  going  "  for  the  first  few  years  of  their 
life,  and  cakes,  confectionery,  pastry,  beer,  coffee,  and 
tea  should  l)e  ligorously  excluded  from  their  dietary. 
In  children,  as  in  adults,  it  is  often  weU  to  forbid  meat 
for  a  time,  especially  in  the  Summer.  Children  as  weU 
as  adults  must  not  drink  beer,  coffee  or  tea;  it  is  best  to 
hmit  their  fluids  to  milk  and  water.  It  is  not  possi- 
ble here  and  now  to  lay  down  any  hard  and  fast  lades 
as  to  diet;  my  object  at  present  is  to  insist  upon  the 


ECZEMA   CAPITIS  ET  BARB.E.  325 

importance  of  regulating  the  diet  of  an  eczematous 
patient. 

The  action  of  the  bowels  is  to  be  regulated,  prefer- 
ably by  diet  and  exercise;  by  drugs  if  we  must.  In  an 
acute  case,  a  sharp  purgative  will  be  found  useful,  and 
my  preference  is  for  the  old-fashioned  remedy,  calomel. 
It  is  best  given  in  small,  repeated  doses,  say  to  an  adult 
one  or  two  grains  repeated  every  two  hours  till  two  or 
three  doses  are  given.  It  unloads  the  bowels,  and  stimu- 
lates the  liver.  Byford  ^'  lays  special  stress  upon  this  lat- 
ter action  in  explanation  of  its  good  effect  in  eczema  of 
children,  and  beheves  that  as  in  them  the  liver  is  larger  in 
proportion  than  in  the  adult,  liver  indigestion  is  proba- 
bly an  important  etiological  factor  in  the  disease.  He 
gives  a  quarter  to  an  eighth  of  a  grain  of  calomel  twice 
a  day  to  an  infant  until  slight  purgation  is  caused,  and 
afterwards  as  often  as  the  bowels  need  it.  In  children 
over  two  and  one  half  years  of  age  he  gives  a  single 
purgative  dose  every  six  to  eight  days.  The  adminis- 
tration of  calomel  is  also  of  service  in  chronic  cases  in 
adults,  and  I  often  give  it  in  the  form  of  tablet  tritu- 
rates in  doses  of  from  a  tenth  to  a  fifth  of  a  grain  three 
or  four  times  a  day  for  three  or  four  days  and  then  stop 
for  a  few  days.  Podophyllin  may  be  used  in  propor- 
tionate doses  and  for  the  same  purpose,  and  also  with 
good  results.  Acids  and  alkalies  are  useful  in  appro- 
priate cases  for  the  regulation  of  the  digestion. 

Local  Treatment.— The  indications  to  be  met  by 
the  local  treatment  of  eczema  are  to  soothe  an  acutely 
inflamed  skin;  to  stimulate  it  when  in  a  state  of  sub- 
acute or  chronic  inflammation;  and  to  protect  it  when 
it  is  endeavoring  to  reassume  its  normal  condition. 
To  know  what  we  want  to  accomplish  is  of  more  im- 
portance in  this  disease  than  to  know  Avhat  is  the  lat- 

*  Jour.  Amer.  Med.  Assoc,  1885,  V.  317. 


326  DISEASES   OF   THE   HAIR   AND   SCALP. 

est  drug  that  is  ^'  good  for  eczema. "  Before  using  any 
remedy  all  ciTists  and  scales  must  be  removed  by  soap 
and  water,  and  after  that  is  accompUshed  no  water 
should  be  used  upon  the  scalp  excepting  at  intervals. 
If  om-  remedies  are  properly  used,  crusts  will  not  re- 
form. Stiff  ointments  should  not  be  used  on  hairy  parts 
where  the  hair  is  thick,  as  it  mats  the  hair  and  makes 
the  scalp  more  miclean  than  before.  Alcohol,  water, 
oil  and  vasehne  are  our  best  excipients.  The  hair  need 
never  be  cut,  and  should  never  be  sacrificed  in  women. 
In  young  children  and  in  boys  our  treatment  is  ren- 
dered easier  by  cutting  the  hair,  but  it  is  not  neces- 
sary. In  applymg  remedies  to  the  scalp  they  should 
be  worked  in,  and  not  merely  smeared  over  it. 

In  an  acute  moist  eczema  of  the  scalp,  the  head 
should  be  satm-ated  with  olive  or  sweet  ahnond  oil,  and 
covered  with  a  linen  cap.  The  oil  should  be  reapplied 
until  the  acuteness  of  the  inflammation  has  subsided. 
Sometimes  the  addition  of  an  alkah  to  the  oil  will  be 
useful,  such  as  the  bicarbonate  of  soda  or  borax  ( 3  iv  to. 
viii.  ad.  Oj);  or  hme- water  in  equal  parts  with  oil.  A 
weak  carbolized  oil,  say  one  per  cent,  of  carbolic  acid,  or 
glycerine  diluted  with  water,  answers  admirably  in  some 
cases.  In  a  few  clays  the  acuteness  of  the  disease  will  sub- 
side under  this  soothing  plan  of  treatment.  Then  the 
scalp  is  to  be  thoroughly  cleaned  ^\'ith  soap  and  water, 
and  the  treatment  proper  to  the  condition  of  the  scalp 
used.  The  scalp  will  bear  stimulating  applications  much 
better  than  the  rest  of  the  integument;  so  as  soon  as  the 
acuteness  of  the  disease  is  past  we  can  use  a  weak  tar 
lotion,  say  half  a  drachm  of  oil  of  cade  to  the  ounce 
of  ohve  oil. 

In  acute  erythematous  and  papular  eczema,  besides 
carbohzed  oil  or  vaseline  we  may  use  black  wash,  or 
a  weak  white  precipitate  ointment,  say  ten  to  twenty 
grains  to  the  oimce.     The  squamous  stage  wiU  soon 


ECZETJA   CAPITIS   ET   BARB^.  327 

be  reached  and  more  stimulating  measures  called  for. 
The  treatment  for  acute  moist  eczema  will  be  appro- 
priate for  an  acute  pustular  eczema  when  it  occurs  in 
a  violent  outbreak  of  pustules  forming  patches  and 
discharging  freely  As  generally  met  with,  this  form 
of  eczema  occurs  in  patches  covered  with  crusts.  The 
crusts  must  be  first  removed  by  soaking  them  in  oil 
for  twelve  or  twenty-four  hours,  and  then  washing  the 
head  with  soap  and  water.  After  the  scalp  is  clean  it 
is  to  be  freely  anointed  with  oil  either  carbohzed,  or, 
better,  with  oil  of  cade,  half  a  drachm  to  one  drachm 
to  the  ounce.  Sometimes  sulphur  one  drachm  in  vase- 
line one  ounce  will  do  good  service  in  this  form  of  ec- 
zema; but  it  is  uncertain,  and  apt  to  prove  irritating. 
Mercurial  ointments,  say  of  calomel  twenty  to  thirty 
grains  to  vaseline  one  ounce,  or  that  of  the  white  pre- 
cipitate ointment  already  spoken  of  will  be  beneficial. 

When  the  squamous  stage  is  reached  we  need  stim- 
ulation, and  for  this  the  best  remedies  are  frictions 
with  soap  and  water,  and  preparations  of  tar.  Once 
or  twice  a  week  the  scalp  is  to  be  washed  with  the 
tincture  of  green  soap,  or  equal  parts  of  soft  soap  and 
alcohol,  or  if  the  scalp  is  very  tender  and  irritable  a 
milder  soap  such  as  Sarg's  liquid  glycerine  soap,  or 
pure  castile  soap  may  be  used.  The  washings  should 
be  repeated  at  intervals  of  a  few  days  to  a  week  or 
more  according  to  their  effect  on  the  scalp.  If  they 
prove  very  irritating  they  are  to  be  less  frequently 
used.  After  washing,  the  scalp  is  to  be  carefully  dried 
and  anointed  with  some  oil  or  soft  ointment  contain- 
ing tar  such  ae; 

01.  Cade,         .         .  3  ss— ij=2  to  16. 

01.  Olivae  ad,     .        .         3  j        =         30. 
M. 

raid  this  is  to  be  applied  every  morning  and  evening. 


32S  DISEASES   OF   THE   HAIR  AND   SCALP. 

Instead  of  the  olive  oil  as  a  vehicle  we  may  use  vase- 
line, oil  of  sweet  almonds,  or  agnine  or  lanoline  di- 
luted, as  with  castor  oil,  sufficiently  to  make  tliem 
supple.  This  has  proved  itself  to  be  in  my  hands  the 
most  efficient  mode  of  treating  subacute  and  chronic 
eczema  of  the  scalp.  Its  only  objectionable  feature  is 
its  odor,  and  this  is  so  pungent  and  persistent  that 
many  patients  will  not  use  it.  Unfortunately  we  have 
no  means  of  successfully  disg-uismg  the  odor.  Instead 
of  the  oil  of  cade  we  may  use  pix  hquida  or  the  oleum 
iTisci,  but  there  is  no  particular  advantage  in  these 
other  forms  of  tar,  and  the  odor  is  the  same  or  worse. 
The  oil  of  cajeput  may  be  substituted  for  the  tar  in 
five  to  ten  per  cent,  strength,  but  it  is  not  so  good.  Car- 
bolic acid  five  to  fifteen  grains  to  the  ounce  may  be 
used,  and  sahcyhc  acid  in  three  to  five  per  cent, 
strengths. 

Instead  of  using  oily  applications  we  may  sometimes 
do  better  with  oil  of  cade  or  pix  liquida  exhibited  in 
alcohol,  one  to  two  drachms  to  the  ounce.  Bulkley 
(5)  recommends  a  lotion  composed  as  follows: 


Acetate  of  lead. 

gi\  viij. 

.      .5 

Oil  of  bergamot, 

3ss 

2. 

Castor  oil. 

.  3iv     . 

.   16. 

Alcohol  ad, 

siv 

120. 

M. 

Napthol  /5,  napthalin,  pyrogallol,  in  the  strength  of 
five  to  ten  per  cent,  may  be  tried  if  other  things  fail. 
Kesorcm  has  of  late  been  highly  commended  by  Ihle  - 
and  others;  and  icthyol  by  UNNA.f  In  many  cases  of 
eczema  in  which  the  scalp  is  much  thickened,  the 
treatment  is  best  begun  by  having  the  patient  wear  a 
close-fitting  cap  made  of  sheet  rubber,  and  its  use  con- 

*  Monatshft   f.  prakt.  Derm.  1885,  IV.  430. 

f  Monatshft  f.  prakt.  Derm.  1886,  V.  Erganzungsheft  No.  2,  in  Mai. 


ECZEMA   CAPITIS   ET  BAKB^.  329 

tinued  till  the  scalp  becomes  moist  and  less  thick. 
Then  tar  may  be  employed. 

After  the  eczema  has  been  cured  the  scalp  may  be 
left  dry  and  scaly,  and  then  it  should  be  treated  ac- 
cording to  the  principles  given  in  Chapter  XIX.  on  Dan- 
druff. 

Prognosis. — Though  eczema  capitis  is  a  very  obstin- 
ate disease  at  times,  still  it  is  perfectly  curable.  Some 
cases  yield  readily  to  treatment,  while  others  will  tax 
our  patience  and  resources  to  the  utmost. 

ECZEMA    BARB^. 

Synonyms: — Impetigo  sycosiforme;  Achor  barbatus; 
Barber's  itch. 

Symptoms: — Eczema  of  the  beard,  which  has  been 
often  erroneously  called  '^barber's  itch,"  has  nearly 
the  same  symptoms  as  eczema  of  the  scalp.  It  may 
be  of  the  erythematous,  vesicular,  papular,  pustular  or 
squamous  variety,  though  by  far  the  great  majority  of 
cases  are  of  the  last  two  forms.  The  erythematous,  pap- 
ular, and  vesicular  varieties  have  precisely  the  same 
clinical  picture  as  the  corresponding  affections  of  the 
scalp.  Most  all  of  the  cases  are  pustular  in  character 
and  we  shall  speak  only  of  that  form. 

Pustular  eczema  of  the  beard  may  be  either  acute  or 
chronic;  may  affect  only  one  limited  area,  or  the  whole 
beard;  may  be  either  symmetrical  or  asymmetrical; 
and  it  may  be  confined  to  the  bearded  portion  of  the 
face  or  pass  over  to  the  unbearded  portions  and  to  the 
neck.  Not  infrequently  the  eyebrows  and  eyelashes 
will  be  affected  at  the  same  time  and  in  the  same  way. 
When  the  disease  is  acute  the  affected  part  or  parts 
are  swollen,  tender  and  red,  and  feel  stretched  and 
burning.  Upon  the  red  skin  there  will  be  an  eruption 
of  small  pin-head  sized  pustules  which  have  no  specinl 
relation  to  the  hairs,  though  many  of  them  do  occur 


330  DISEASES   OF   THE   HAIR   AND   SCALP. 

about  the  months  of  the  hair-folUcles.  These  pustules 
break  of  themselves  in  a  very  short  time  and  discharge 
their  purulent  contents,  which  glues  the  hairs  together. 
If  the  disease  is  very  acute  and  violent  the  beard  will 
look  as  if  some  mucilaginous  fluid  had  been  poured  over 
it.  Soon  the  exudation  will  dry  into  greenish  or  yel- 
lowish-green thick  crusts,  in  which  the  hairs  ^vill  be 
entangled  and  matted  together.  When. the  crusts  are 
removed  a  moist  exuding  surface  will  be  exposed. 
The  hair  will  be  unaffected  excepting  that  it  is  stuck 
together;  and  attempts  at  epilation  will  be  painful. 

In  subacute  and  chronic  cases  the  hair  will  be  some- 
what tliin,  leaving  the  under-lying  skin  exposed.  This 
will  be  red  and  scahng  in  some  places,  covered  with 
greenish  crusts  in  other  places,  and  studded  here  and 
there  with  small  pustules,  either  about  the  mouths  of 
the  hair-foUicles  or  independently  of  them.  It  will  be 
seen  that  the  skin  between  the  hairs  is  diseased  as  well 
as  about  the  hairs.  To  these  subacute  and  chronic 
cases  sycosis  is  apt  to  join  itself,  or  the  eczema  may 
pass  over  into  a  sycosis. 

Squamous  eczema  of  the  beard  is  the  final  stage  of 
the  other  varieties,  through  which  they  pass  on  their 
way  towards  recovery.  In  it  the  skin  is  reddened  and 
thickened  and  covered  with  scales.  Very  often  the 
progress  of  the  disease  is  stayed  at  this  point  and  re- 
covery does  not  set  in.  On  the  contrary,  relapses  are 
liable  to  occur  even  after  the  squamous  stage  has  lasted 
for  some  time. 

Itching  accompanies  all  varieties  of  eczema  of  the 
beard,  and  is,  excepting  the  deformity,  the  most  an- 
noying feature  of  the  disease. 

Etiology. — This  form  of  eczema  is  comparatively 
rare.  In  1800  consecutive  skin  cases  occurring  in  Dr. 
Geo.  Henry  Fox's  service  at  the  New  York  Skin  and 
Cancer  Hospital,  it  was  seen  only  sixteen  times.     Of 


ECZEMA  CAPinS  ET  BARB.E.  331 

course  it  occurs  only  in  men.  It  is  predisposed  to  by 
the  same  constitutional  disturbances  as  we  noted  un- 
der eczema  of  the  scalp.  Its  exciting  causes  are  also  in 
large  part  the  same  as  noted  in  the  previous  section  of 
this  chapter.  Exposure  to  dust  and  wind  and  weather; 
the  irritations  from  tobacco  smoke,  or  the  secretions 
from  nasal  catarrh;  the  application  of  poultices  for  the 
relief  of  neuralgia;  scratching  of  the  beard  either 
from  habit  or  on  account  of  the  itching  due  to  seborr- 
hoea,  and  shaving,  may  be  noted  as  special  exciting 
causes. 

Diagnosis. — Eczema  of  the  beard  is  to  be  diagnosed 
from  sycosis,  trichophytosis  barbae,  acne,  a  pustular  or 
tubercular  syphilide,  and  an  epithehoma. 

Eczema  is  a  more  superficial  process  than  sycosis', 
its  pustules  have  no  close  relation  to  the  hairs,  it  is 
very  itchy,  its  crusts  are  thick  and  seated  upon  a  moist 
and  oozing  surface,  the  hair  is  unaffected,  and  it  is 
often  associated  with  the  same  disease  on  other  parts 
of  the  face  or  general  integument.  Sycosis  is  a  deep 
perifollicular  inflammation,  its  lesions  are  seated  about 
the  hair- follicles,  the  skin  between  the  hairs  being 
unaffected  except  in  old  and  severe  cases,  its  crusts 
are  not  so  thick  as  those  of  eczema  and  do  not  mat  the 
hairs  together,  and  it  occurs  only  upon  places  supplied 
with  hair.  It  burns  rather  than  itches,  and  the  hairs 
are  readily  pulled  out. 

Trichophytosis  barbcB  has  a  history  of  spreading 
from  one  or  two  points,  and  often  can  be  traced  to  a 
source  of  contagion.  It  is  generally- confined  to  the 
chin  and  throat,  and  its  lesions  are  tubercles  and  nod 
ules.  The  hair  is  early  aftected,  is  broken  off  and  is 
readily  pulled  out,  or  falls  out  of  itself.  The  crusts 
are  small  or  wanting.  It  often  extends  beyond  the 
beard  as  a  typical  ringworm,  or  ringworms  may  be 
found  on  other  parts  of  the  body.     These  symptoms 


'^3^  DISEASES   OF   THE   HAIR   AND   SCALP. 

are  so  characteristic  that  the  two  diseases  should  not 
be  confounded. 

Acne  occurs  as  isolated  and  discrete  pustules  or  small 
cutaneous  abscesses  on  all  parts  of  the  face,  and  come- 
dones are  generally  to  be  found.  The  skin  between  the 
pustules  is  unaffected;  there  is  no  exudation,  and  no 
itching. 

In  s2/p/r«7/.s  there  will  be  other  lesions  elsewhere  on 
the  body,  and  a  history  of  an  initial  lesion  ov  of  some 
other  manifestation  of  the  disease.  The  lesions  are 
discrete,  and  if  there  are  crusts,  well-marked  specific 
ulcers  will  be  found  beneath  them  when  they  are  re- 
moved. 

It  would  hardly  seem  possible  to  confound  an  eczema 
with  an  epithelioma,  but  it  has  been  done.  An  epith- 
ehoma  occurs  as  a  single  lesion,  rounded  or  irregular 
in  outline,  of  varying  size  from  that  of  a  one  cent 
piece  to  that  of  the  palm,  and  forms  a  weU-marked  ulcer 
with  raised  hard  waxy  borders  over  which  run  delicate 
branching  blood-vessels.  The  ulceration  may  be  only 
superficial  and  covered  with  a  delicate  crust,  but  it  is  al- 
ways sharply  defined  and  bleeds  easily.  An  eczema  has 
no  weU-defined  shape  or  border,  and  no  raised  edge. 
An  epithelioma  is  painful,  the  i^ain  being  lancinating 
at  times,  while  an  eczema  is  itchy. 

Prognosis. — The  obstinacy  of  the  disease,  and  it  is 
often  exceedingly  rebellious  to  treatment,  is  due  to 
the  irritation  of  the  skin  by  the  stiff  hairs  of  the  beard. 
Though  the  disease  is  obstinate  it  is  perfectly  curable; 
but  it  is  liable  to  relapses,  and  it  is  good  policy  to  let 
oiu"  patient  know-  tliis  before  beginning  treatment. 

Treatment. — The  treatment  of  eczema  of  the  beard 
is  conducted  on  the  principles  we  have  learned  in 
studying  the  same  disease  of  the  scalp,  but  modified 
in  some  particulars  to  suit  the  changed  conditions. 
When  we  can  prevail  upon  the  patient  to  cut  his  beard 


fiCZEMA   CAPITIS   ET  BARB^.  333 

close,  we  have  taken  a  long  step  towards  curing  the 
disease.  Many  patients  prefer  to  allow  the  beard  to 
grow,  as  it  serves  to  disguise  the  disfigurement  to  a 
certain  extent:  but  we  can  apply  our  dressings  much 
better  if  we  get  rid  of  the  hair.  Shaving  may  be  prac- 
tised and  is  recommended  in  many  text-books  :  but  it 
is  very  painful  in  the  acute  stage  of  the  disease  and 
unnecessary  if  the  hair  is  clipped  close.  In  the  squa- 
mous stage  it  should  be  advised  because  of  its  stimula- 
ting effect.  The  first  step  in  treatment  is  to  remove 
from  the  patient  any  irritant  that  has  been  acting  upon 
his  skin.  If  the  case  is  a  bad  one  we  should  have  the 
patient  stay  at  home  until  the  violence  of  the  disease 
is  abated.  Even  then  a  cure  can  be  secured  more 
speedily  if  the  patient  will  consent  to  stay  in  the  house 
during  its  whole  course. 

In  acute  eczema  of  the  beard,  after  the  hair  is  cut 
close,  a  soothing  application  should  be  used.  To  this 
end  we  may  employ  a  carbolized  oil,  simple  oil,  black 
wash,  lime-water  and  oil,  zinc  oxide  ointment,  simple 
ointment,  or  Lassar's  paste,  the  latter  composed  as 
follows: 

Starch, 

Zinc  oxide,  .         .         .     aa3ij  =  8. 

Vasehne  ad,      .        .        .        .      3J  =32. 
M. 

answers  admirably.  Diachylon  ointment  is  also  excel- 
lent. In  this,  as  well  as  the  more  chronic  form,  tunie- 
nol  oil  will  often  render  good  service  if  the  patient  does 
not  object  to  the  black  color.  Whatever  dressing  is 
selected,  it  should  be  used  freely,  the  ointments  being 
spread  thickly  upon  cloths,  and  bound  down  to  the 
part  with  a  roller  bandage.  In  Vienna  even  the  acute 
cases  are  treated  by  scrubbing  the  skin  with  green  soap 


33^  DISEASES  OF  THE  HAIR  ANT)  SCALP. 

or  its  tincture,  and  following  this  with  the  diachylon 
ointment. 

As  soon  as  the  acuteness  of  the  disease  has  some- 
what subsided  we  should  proceed  to  more  active  meas- 
ures. All  crusts  must  be  gotten  lid  of  by  soaking  with 
oil  and  subsequent  washing  with  soap  and  water.  All 
haii-s  protruding  from  pustules  should  be  plucked  from 
their  folhcles.  Now  the  tar  preparations  spoken  of  in 
the  section  on  eczema  capitis  may  be  used,  or  mild 
sulphm-  ointment.  Lassar's  paste  with  the  addition 
of  about  fifteen  grains  of  sahc^^hc  acid  to  the  ounce  is 
soothing  and  efficient  at  this  time.  When  the  squam- 
ous stage  is  reached  the  beard  should  be  shaved  off 
every  day  or  so,  and  then  the  stimulating  remedies  ap- 
plied. As  the  disease  becomes  reduced  to  a  slight  red- 
ness and  the  patient  is  going  about  liis  usual  avoca- 
tions, the  skin  should  be  protected  by  a  shght  film  of 
vaseline  or  ointment,  or  with  a  dusting  powder.  In 
fact  throughout  the  treatment,  if  the  patient  is  obhged 
to  go  out  he  must  protect  the  skin  in  this  way,  and 
employ  the  more  radical  di'essings  at  night. 

ECZEMA  PALPEBRARUM. 

This  foiTU  of  eczema,  which  is  also  called  Eczema 
marginis  ciliaris  pcdpehraruin,BJidi  Blepharitis  ciliaris, 
is  seen  by  the  opthahnologist  more  often  than  by  the 
dermatologist.  Eczema  of  the  eyehds  usually  accom- 
panies the  same  disease  on  other  parts  of  the  head, 
though  it  may  occur  on  them  alone.  It  is  always  pus- 
tular in  character  at  first,  and  afterwards  squamous. 
The  edges  of  the  hds  are  swollen  and  rounded,  and 
more  or  less  thickly  strewn  with  pustules  that  quite 
commonly  are  situated  al)out  the  cilia  and  take  on  a 
sycosiform  character.  The  lids  after  sleep  are  stuck 
together  so  as  to  be  opened  with  difficulty.  The  pus^ 
tules  rupture,  and  then  the  edges  of  the  lids  become  cov 


ECZEMA   PALPEBRARUM.  335 

ered  with  yellowish  or  greenish  crusts.  When  the 
crusts  are  removed  excoriations  are  left,  and  some- 
times even  small  ulcers.  The  skin  itches,  and  the  rub- 
bing by  the  patient  for  its  rehef  aggravates  the  disease. 
When  the  process  passes  over  into  the  squamous  form 
the  edges  of  the  hds  are  merely  red  and  scaly.  If  the 
inflammation  about  the  cilia  has  beeu  intense  and  ul- 
cers have  formed,  cicatrisation  will  follow  and  loss  of 
the  eyelashes.  Both  Hds  are  usually  affected,  and  the 
disease  is  commonly  symmetrical. 

With  the  blepharitis  there  will  be  more  or  less  con- 
junctivitis, with  its  characteristic  symptoms.  The 
eyebrow,  also,  is  often  eczematous.  Sometimes  the 
disease  will  remain  confined  to  the  corners  of  the  eye, 
especially  the  outer  canthus,  for  a  long  time. 

Etiology.— This  disease  is  seen  most  commonly  in 
strumous  subjects,  and  is  a  frequent  complication  of 
phlyctenular  ophthalmia  and  other  strumous  eye  trou- 
bles in  children.  When  occurring  with  eczema  else- 
where it  is  an  expression  of  the  eczematous  condition. 
When  occurring  alone  it  is  most  frequently  caused 
either  by  some  trouble  with  the  eye  itself,  or  by  appli- 
cations made  to  the  eye  for  the  relief  of  such  troubles. 
Sometimes  it  is  difficult  to  determine  whether  a  con- 
junctivitis has  caused  the  eczema,  or  an  eczema  has 
provoked  a  conjunctivitis. 

Treatment.— The  eyes  should  be  bathed  with  warm 
water  to  remove  the  crusts,  and  then  anointed  to 
prevent  their  sticking  together.  This  should  be  done 
especially  before  the  patient  goes  to  sleep.  What  oint- 
ment is  to  be  used  will  depend  upon  the  condition.  In 
mild  cases  simple  ointment  will  suffice.  Generally 
some  form  of  mercurial  ointment  will  do  better,  such 
as  that  of  the  red  or  yellow  oxide  diluted  eight  or  ten 
times  with  vaseline  or  simple  ointment.  A.  R.  Robin- 
son recommends  an  ointment  composed  of  one  grain 


330  DISEASES   OF   THE   HAIR   AND   SCALP. 

of  the  biniodide  of  mercury  in  one  ounce  of  vaseline. 
Deligxy  has  found  the  best  apphcation  to  be  :  Plumbi 
acetat.  0.25,  Adeps.  25.  La wsox  regards  ointments  as 
too  irritating,  and  advises  the  following  wash  : 

IJ  Boracis  vel  zinc  oxid,         .       3ij,  say    1.5 

Glycerin,         .         .  .  3iv     ^'     3. 

Aqua?  sambuci,  .         .       3  ij      *^  12. 

Aqua^  destil.  ad      .  .  rviij'^lOO. 

M. 

Another  good  remedy  I  owe  to  Prof.  D.  Webster, 

and  is  as  follows: 

I^  Ac.  sahcylici,  .         .         .  gr.  x,  say     .8 

Ungt.  hydrarg.  oxid.  rubri,  3  i  ^'      5. 

Ungt.  aqua?  rosa?,    .         .  3  vi       ^'    30. 

M. 

Whether  we  use  ointments  or  lotions  we  must  be 
sure  that  any  powders  that  enter  into  them  are  of  the 
finest,  so  that  matters  are  not  made  worse  by  the  irri- 
tation of  coai-se  grains  left  l^y  the  apphcations. 

When  the  process  becomes  sycosiform  the  ciha  must 
be  plucked  from  the  lids.  If  the  disease  prove  very 
obstinate  we  may  evert  the  lids  and  binish  over  them 
a  solution  of  caustic  potash,  ten  grains  to  the  ounce, 
alisorbing  the  superfluoits  fluid  with  blotting  paper  and 
then  washing  with  water.  This  should  be  done  every 
day  until  there  is  an  amelioration  of  the  symptoms, 
when  one  of  the  mercurial  ointments  may  be  used.  In 
aU  cases  constitutional  treatment  must  be  prescribed, 
as  well  as  special  treatment  f<  /r  the  eyes,  w^here  these 
are  diseased. 

eczema  of  other  hairy  parts. 

Tlie  hair  on  any  part  of  the  body  may  be  attacked  by 
eczema  and  give  rise  to  symptoms  corresponding  to  those 


ECZEMA   CAPITIS   ET   BARB^.  S^t 

just  detailed.  Thus  we  have  eczema  of  the  axilla  and  of 
the  pubes;  a  very  annoying  eczema  of  the  hairs  in  the 
nostrils;  and  a  peculiar  form  of  follicular  eczema  which 
affects  the  hairs  of  tlie  extremities  or  trunk. 

The  treatment  of  eczema  of  the  axilla  and  pubes  is 
the  same  as  for  the  same  disease  of  the  beard. 

Eczema  of  the  hairs  of  the  nares  is  often  obstinate. 
We  must  endeavor  to  cure  the  nasal  catarrh  that  is 
usually  present,  and  to  apply  ointments  to  the  part  on 
pledgets  of  lint.  Sometimes  we  may  have  to  epilate 
and  apply  a  solution  of  nitrate  of  silver.  Hardaway  * 
believes  this  condition  is  associated  in  many  cases  with 
a  broken-down  state  of  health,  and  recommends  active 
internal  treatment.  For  the  local  treatment  he  has 
found  Squire's  glycerole  of  the  subacetate  of  lead  of 
special  service.  This  is  made  by  mixing  together  ace- 
tate of  lead  5  parts,  litharge  3^  parts,  and  glycerine  20 
parts,  by  weight,  heating  to  350°  F.  and  filtering 
through  a  hot-water  funnel.  He  opens  the  Httle  ab- 
scesses with  a  knife  and  when  the  disease  is  abated  ap- 
plies 

Squire's  glycerole  plumb,  subacetat,  3  ss  say  2. 

Glycerine,        .        .        .        .  3iss  "    6. 

Ungt.  aq.  rosae  ad,       .        .        .         Ij      "  32. 

Cerse  albae, qs.     "  qs. 

M. 

In  very  obstinate  and  relapsing  cases  he  epilates 
the  offending  hairs  by  electrolysis.  Eczema  seated 
about  the  hair-follicles  of  the  trunk  and  extremities 
is,  happily,  rare,  and  is  sycosic  in  its  nature.  I  have 
seen  it  only  in  a  very  few  cases  and  then  upon  the  legs 
of  strumous  subjects.  It  occurs  as  disseminated  and 
discrete  papules  and  pustules  pierced  by  hairs,  and  is 
very  itchy,  so  that  excoriations  are  frequently  seen.    It 


*  Jour.  Cut.  and  Veu.  Dis.,  1880,  iV.  360. 


338  DISEASES   OF   THE    HAIR  AND  SCALP. 

has  always  proved  obstinate  to  treatment.  A  cure  can 
be  effected  only  by  attention  to  the  general  physical 
state.  Locally  the  disease  is  to  be  treated  on  the  prin- 
ciple of  sycosiSo 


CHAPTER  XXIL 

PLICA  POLONICA. 

Synonyms: — Trichosis  plica;  Trichoma;  Koltun  (Po- 
lish); Weichselzopf  (Ger.);  Plique  polonaise  (Fr.); 
Polish  ringworm  (Eng.). 

Symptoms: — The  term  Plica  Polonica  is  used  rather 
to  designate  a  condition  than  a  disease,  the  condition 
arising  from  various  causes  and  producing  the  cUnical 
picture  of  the  long  hair  of  the  head  or  other  parts 
matted  together  into  various  shaped  masses,  in  and  on 
which  rest  all  sorts  of  extraneous  matters  deposited 
from  the  floating  dust  of  the  atmosphere,  and  very 
often  vast  hordes  of  pedicuh  with  their  ova.  At  times 
these  masses  of  matted  hair  will  be  close  to  the  skin  or 
scalp;  at  times  removed  to  a  considerable  distance 
from  it.  If  close  to  the  scalp  we  will  find  beneath 
them  a  moist  and  oozing  condition  of  the  under-lying 
part;  if  at  a  distance  from  the  scalp,  the  latter  may  be 
of  normal  appearance,  or  scaly.  This  is  due  to  the 
age  of  the  plica,  the  freshly  formed  ones  are  near  the 
scalp,  and  when  the  disease  of  the  scalp  is  recovered 
from,  the  growing  hairs  will  push  the  mass  further  and 
further  from  the  scalp  until  it  either  falls  off  of  itself 
or  is  cut  off.  Various  names  have  been  used  to  desig- 
nate the  different  shapes  these  masses  may  take;  thus 
when  the  hair  is  short  and  there  are  many  locks 
matted  separately  it  is  called  plica  multiformis,  or 
caput  Medusa;  when  but  a  single  coil,  and  this  long 
and  in  the  shape  of  a  tail,  it  is  called  plica  caudif  ormis, 
and  such  tails  may  be  so  long  as  to  reach  below  the 
knees.     The  odor  of  the  head  in  plica  polonica  is  pene- 


A  Caudiform  Plica  Po  lo>'ICA. 


PLICA  POLONICA.  841 

trating  and  disgusting;  somewhat  like  that  of  rancid 
fat.  There  are  no  special  constitutional  symptoms; 
the  patient  may  be  cachectic,  strumous,  phthisical  or 
what  not;  or  he  may  be  perfectly  sound  and  healthy. 
The  only  subjective  symptom  is  itching. 

Such  is  the  disease  as  viewed  in  the  light  of  modern 
medicine  since  the  time  when  Hebra  demonstrated  its 
dependence  upon  lack  of  care  of  the  hair.  Previous  to 
that  it  was  described  as  a  disease  with  four  stages 
namely:  1.  Prodromal  stage;  2.  Stage  of  exudation; 
3.  Stage  of  efflorescence;  4.  Stage  of  convalescence. 
It  was  regarded  as  a  safety-valve  in  severe  illnesses, 
and  it  w^as  thought  that  if  the  patient  could  raise  a 
plica  he  would  recover  from  his  disease.  It  was  on 
that  account  held  sacred  from  injury,  and  cases  were 
reported  in  which  a  man  or  woman  died  in  conse- 
quence of  cutting  off  his  or  her  phca.  PHcas  have 
been  described  as  having  taken  on  a  fleshy  condition, 
and  reported  as  having  bled  from  the  stump  wiien 
cut  off,  or  at  least  to  have  exuded  a  reddish  fluid. 
These  were  without  doubt  errors  in  observation. 

ETioiiOGY. — The  cause  of  this  condition  of  the  hair 
is  want  of  cleanliness  combined  with  the  presence  of 
lice,  giving  rise  to  pediculosis;  or  of  any  disease  of  the 
scalp  which  is  accompanied  by  moisture,  principally  ec- 
zema. But  this  was  not  always  thought  to  be  the  case, 
and  the  literary  war  was  long  and  stubborn  before  this 
theory  gained  the  victory  over  the  old  theories  that 
regarded  the  condition  as  a  specific  disease.  It  used 
to  be  regarded  as  a  dyscrasia  occurring  endemically  in 
certain  countries,  especially  in  certain  provinces  of  Rus- 
sia and  Poland.  It  was  thought  to  occur  at  the  crisis 
of  many  diseases,  and  was  regarded  as  of  favorable 
prognosis.  The  common  people  had  such  great  faith 
in  the  salutary  influence  of  a  plica  that  they  often  pro- 
duced one  by  the  use  of   wax,  pitch  and  the  like. 


342  DISEASES  OF  THE   HAIR  AND  SCALP. 

Such  an  one  was  called  a  false  plica.  It  was  and 
even  now  is  endemic  in  certain  parts  of  Poland,  and 
especially  in  the  low-lying  provinces,  because  the 
people  are  wonderfully  careless  about  personal  cleanli- 
ness, and  are  in  the  habit  of  wearing  fur  caps  con- 
stantly upon  their  heads,  inducing  sweating  and  favor- 
ing an  eczematous  condition.  It  is  seen  both  in  men 
and  women,  and  while  most  common  amongst  the 
lower  ranks  of  society,  it  is  met  with  also  in  the  nobility 
of  Poland  and  Russia.  We  encounter  the  condition 
now  and  again  in  this  country,  but  of  mild  grade,  and 
as  an  unmistakable  result  of  want  of  care  of  the  scalp. 

Treatment. — The  condition  is  removed  very  readily 
by  soaking  the  hair  T\ath  oil,  washing  with  soap  and 
water,  and  carefully  combing;  all  combined  with  the 
exercise  of  great  patience  and  perseverance.  If  the 
mass  has  gro^vn  away  from  the  scalp  the  easiest  way 
of  treating  it  is  by  cutting  it  off.  After  the  phca  is 
disposed  of,  we  must  apply  ourselves  to  the  cure  of  the 
disease  of  the  scalp  that  is  at  the  bottom  of  the 
trouble.  The  older  writers  endeavored  to  treat  the 
disease  by  internal  medication.  Rosenberg  (76)  gives 
seventy  remedies  recommended  at  different  times  for 
the  cure  of  the  disease. 

Besides  this  true  or  phca  polonica,  there  is  a  form  of 
felting  of  the  hair  which  is  apparently  due  to  nervous 
influences,  probably  of  an  hysterical  nature.  Cases  of 
this  kind  have  been  reported  from  time  to  time  under 
the  name  of  neuropathic  or  nervous  phca.  Recently 
Le  Page  (620)  has  reported  a  case  of  spontaneous  and 
rapid  felting  of  the  hair  in  a  girl  seventeen  years  of 
age;  and  Pestonji  (623)  has  related  another  occurring 
in  a  woman  twenty  years  old.  Jarochevski  (427  ap.) 
reported  another  case  in  an  hysterical  young  woman. 
Microscopical  examination  showed  the  cuticle  of  the 
hair  to  be  entirely  separated  from  the  cortex,  rough, 


PLICA   POLONICA.  343 

and  its  fibres  split  up.  Its  cortex  showed  irregular 
disposition  of  pigment,  and  its  medulla  was  broken 
up.  De  Amicis  (426  ap.)  has  also  reported  a  case.  In 
all  cases  the  hair  had  been  wet  before  it  began  to  twist 
up,  and  in  both  there  was  headache  and  an  entire  ab- 
sence of  disease  of  the  scalp. 


CHAPTEE  XXIII. 

DER^L\TITIS  PAPILLARIS   CAPILLITH. 

Synonyms:  —  Dermatitis  papillomatosa  capillitii; 
Frambcjesia;  S}XOsis  framboesia  (Hebra);  Sycosis 
capillitii  (^Rayer);  Mycosis  frambcesioides  or  acue 
keloidique  or  Pian  ruboide  (  Alibert);  Acne  keloid. 

Symptoms: — Tliis   exceedingly  rare  disease   of   the 


Dermatitis  Papillaris  Capillitii. 

skin  was  first  described  as  a  separate  entity  by  Kaposi 
(<;20)  in  ISOO.  The  same  group  of  symptoms  had  al- 
ready been  described  by  ALiBEPtT  in  ISl^,  but  regarded 
by  him  as  a  manifestation  of  syphilis.  From  time  to 
time  the  disease  had  l>een  ol)served  and  mentioned  by 
the  older  authorities,  and  to  it  the  name  of  Framboesia 


DERMATITIS   PAPILLARIS   CAPILLITII.  34:5 

had  been  applied  on  account  of  the  resemblance  of  its 
peculiar  lesions  to  a  raspberry,  that  being  the  mean- 
ing of  the  word  "  frambcesia.  "  Both  in  Hebra  and 
Kaposi's  Lehrbuch  der  Hautkrankheiten  1S72, 
and  Kaposi's  Patliologie  unci  Thet^apie  der  Hcmt- 
kraiikheiten,^'  18S0,  the  disease  is  placed  in  the  chap- 
ter or  section  on  sycosis.  Kaposi,  in  the  article  re- 
ferred to  and  in  his  book,  described  the  disease  as  fol- 
lows: "  The  primary  manifestations  consist  of  an 
eruption  of  large  and  small  papules  which  are  very 
hard,  of  uniform  consistence,  and  contain  no  pus. 
These  lesions  are  elevated  many  hnes  above  the  skin, 
and  form  variously  sized,  deeply  furrowed,  uneven, 
lobulated  tumors.  They  generally  are  covered  with  a 
thick  epidermis,  bleed  only  when  cut  or  deeply 
wounded,  are  rarely  moist,  and  then  but  in  a  few 
places;  and  the  few  vesicles  or  pustules  that  may  be 
present  are  superficial  and  purely  accidental.  Th? 
papules  are  discrete  at  first,  but  soon  run  together  to 
form  the  tumors,  which  at  last  flatten  down  into  cica- 
tricial tissue.  The  hair  is  deeply  seated  in  the  furrows 
between  the  lobules  of  the  tumors;  is  formed  into  ht- 
tle  bundles  or  wisps;  and  resists  attempts  at  epilation, 
often  breaking  instead  of  coming  out.  Sometimes,  on 
the  other  hand,  it  seems  to  be  retained  only  mechani- 
cally in  the  furrows,  and  comes  out  easily  when  j)ulled 
upon.  It  often  appears  atrophied,  and  sometimes  is 
entirely  wanting  in  large  areas,  but  never  is  connected 
with  a  pustule.  The  disease  begins  in  most  cases  upon 
the  occiput  low  down  at  the  edge  of  the  hair,  and  from 
there  spreads  upwards;  sometimes  involving  the  whole 
posterior  part  of  the  head.  When  so  extensive,  the 
lesions  form  a  papillomatous  vegetation  which  exudes 
a  foul-smelling  secretion,  bleeds  easily  and  is  covered 
with  crusts;  sometimes  abscesses  form." 
Hans  Hebra,  Jr.  (620)  in  1874  reported  a  case  of  '^syco- 


346  DISEASES   OF   THE   HAIR   AXD   SCALP. 

sis  framboesioides  "  Avhich  occurred  upon  the  side  of  the 
head  in  the  form  of  raised  and  sclerosed  patches  sown 
vdih  millet-seed  sized  papules  and  somewhat  larger  pus- 
tules, out  of  which  protruded  httle  bundles  of  hair.  In 
ISSl  Sangster  (63U)  reported  a  case  of  papillary  tumor 
of  the  scalp  which  was  about  the  shape  and  size  of  a 
pigeon's  egg;  situated  low  down  on  the  occiput;  about 
half  an  inch  in  height;  studded  with  hempseed  seized 
papules;  brown  colored  at  the  circumference,  violaceous 
toward  the  centre;  slightly  ulcerated  here  and  there, 
with  thin  crusts.  It  had  begTui  at  birth,  and  was  in- 
creasing gradually  in  size.  The  hah-  was  plentiful  at 
the  margin,  but  sparse  and  devoid  of  pigment  towards 
the  centre,  and  grew  up  between  the  papiUae  without 
piercing  them.  There  was  a  second  tumor  over  the 
left  ear.  Kaposi  pronounced  this  to  be  a  case  of  der- 
matitis jxtplUaris  capiUitii.  Hyde  (628)  has  reported 
two  cases,  in  each  of  which  puncture  caused  a  dis- 
charge of  mucoid  fluid  followed  by  an  exudation  of 
thin  venous  blood  and  serum.  He  describes  the  first 
stage  as  an  eruption  of  pin-head  sized  papules,  vesicles, 
or  vesico-pustules.  Baker  (625)  and  Williams  (632) 
have  reported  cases  under  the  name  of  "Acne  Ke- 
loid. "  Hervouet  (627)  reported  a  case  of  papiUii- 
form  hypertrophy  of  the  scalp,  which  corresponds  in 
many  particulars  to  the  disease  as  described  by  Kaposi. 
Veritee  (631)  has  also  reported  a  case  mider  the  name 
of  Acne  Keloidique.     Another  case  is  by  Eve.* 

Through  the  kindness  of  Dr.  Geo.  H.  Fox,  of  New 
York  city,  I  am  able  to  add  the  followmg  case  which 
I  had  the  opportunity  of  studying  with  him:  J.  E., 
set.  30.  Large,  well-developed  and  healthy  man.  One 
year  ago  (1884)  there  appeared  on  his  neck  an  einiption 
of  hard  nodules,  which  have  been  steadily  increasing 
in  munber  and  size.  The  eruption  is  situated  upon 
the  occiput  amongst  the  han,  and  upon  the  contiguous 

*  Path.  Trans.,  1884,  xxxv.,  397. 


DERMATITIS   PAPILLARIS   CAPILLITII.  34:7 

portions  of  the  neck.  It  consists  of  numerous  small, 
reddish,  hemispherical  tumors,  each  one  of  which  is  per- 
forated by  hairs.  A  few  of  these  tumors  showed  a 
tendency  to  suppurate  about  the  mouths  of  the  folli- 
cles. Some  of  the  tumors  tend  to  become  aggregated, 
and  to  form  mulberry -like  masses  of  dull  red  color. 
The  smaller  nodules  are  very  firm,  and  hard  and  shotty 
to  the  touch.  They  do  not  bleed  readily  when  punc- 
tured. They  are  not  tender  nor  sore,  and  he  is  troubled 
only  by  the  deformity  caused  by  their  presence. 

From  a  study  of  these  cases  we  learn  that  the  dis> 
ease  begins  as  an  eruption  of  papules  of  small  size, 
which  are  usually  few  in  number,  and  situated  upon 
the  back  of  the  neck  at  the  margin  of  the  hair.  These 
papules  are  of  the  color  of  the  skin,  or  slightly  more 
reddish,  and  sometimes  have  an  inflammatoiy  halo. 
They  are  exceedingly  hard  and  firm,  and  do  not  con- 
tain pus.  If  pricked  they  give  vent  to  a  little  bloody 
serous  fluid.  Slowly  they  increase  in  number,  and 
form  larger  raspberry-like  elevations  which  have  un- 
even, lobulated  surfaces.  New  lesions  appear  from 
time  to  time  upon  the  neck  following  the  line  of  the 
hairs,  or  the  disease  encroaches  upon  the  hairy  scalp, 
and  in  the  course  of  months  or  years  it  may  reach 
even  up  to  the  vertex.  When  these  lobulated  masses 
attain  a  certain  size  they  often  become  softened  a  lit- 
tle, and  when  cut  may  be  found  to  contain  pus.  At 
times  they  secrete  a  foul-smelling  fluid,  and  become 
crusted.  When  the  papules  run  together  the  inflam- 
matory halo  disappears.  Gradually  the  growths  be- 
come sclerosed  and  assume  a  keloidal  appearance. 
When  the  hairy  scalp  is  attacked,  pustules  may  forju 
out  of  w^hich  little  bundles  of  hair  protrude;  but  the 
hair  is  not  loosened.  The  keloidal  masses  are  genei'ally 
bald;  but  some  have  a  few  bundles  or  tufts  of  hair  in 
them,  which  usually  is  firmly  seated  and  resistant  to 


348  DISEASES   OF  THE   HAIR  AND   SCALP. 

attempts  at  epilation.  Sometimes  these  tufts  are  ap- 
parently only  mechanically  held  in  the  fm-rows  of  the 
growths  and  are  readily  pulled  out.  Sometimes  the 
hair  when  pulled  appears  healthy;  sometimes  atro- 
phied; sometimes  it  breaks  upon  shght  traction. 

The  disease  may  give  rise  to  some  tenderness  or  may 
be  absolutely  painful.  Sometimes  there  are  no  sub- 
jective symptoms,  and  the  patient  will  complain  only 
of  the  deformity  and  the  inconvenience.  The  course 
of  the  malady  is  exceedingly  slow,  but  steadily  pro- 
gressive. 

Etiology.— The  etiology  of  the  disease  is  very  ob- 
scure. From  its  location  at  the  back  of  the  neck,  at 
about  the  place  where  the  band  of  the  shirt  or  other 
clothing  rubs,  it  has  been  suggested  that  the  rubbing 
of  the  shirt-collar  may  be  an  etiological  factor.  It  oc- 
cm^s  both  in  women  and  men,  and  may  begin  at  any 
age. 

Pathology. — The  disease  process  is  described  by 
Kaposi  as  a  chronic  inflammation  of  the  chorion  prin- 
cipally, attended  by  a  great  increase  in  the  number  of 
the  blood-vessels  and  in  the  size  of  the  papillae.  This 
is  followed  by  the  formation  of  new  connective  tissue, 
w^hich  by  pressure  destroys  the  sweat  and  sebaceous 
glands,  and  finally  compromises  the  existence  of  the 
hair-follicles,  and  the  hair  itself. 

Diagnosis.— The  peculiar  location  of  this  disease 
upon  the  back  of  the  neck  at  the  margin  of  the  haii% 
the  arrangement  of  the  hair  in  little  tufts  in  the  keloidal 
masses,  and  the  great  hardness  of  the  lobulated  or 
papillomatous  tumors,  distmguish  this  malady  from 
all  others.  In  sycosis  w^e  have  no  hard  tumors, 
and  the  hairs  are  surrounded  by  pustules;  in  our  pre- 
sent disease  the  pustules  that  may  be  present  either 
have  no  relation  to  the  hairs,  or  else  suiTOund  a  number 
of  them.     Warts  or  pcq^iUomcfs  of.  the  scalp  lack  the 


DERMATITIS   PAPILLARIS   CAPILLITII.  BttO 

hardness  of  dermatitis  papillaris  capillitii,  do  not  oc- 
cupy the  same  region,  do  not  tend  to  increase  in  size, 
and  do  not  take  on  a  keloidal  condition.  The  large 
uneven  tumors  of  mykosis  fungo'ide  resemble  the 
growths  of  dermatitis  papillaris  capillitii,  but  they 
are  not  quite  so  soft;  they  are  more  generally  distribu- 
ted over  the  whole  body,  come  and  go  in  a  capricious 
manner,  often  break  down  and  ulcerate,  and  do  not 
slowly  change  into  keloidal  tumors  or  streaks. 

Prognosis. —  So  far  as  reported  the  growths  are  be- 
nign and  are  compatible  with  a  good  state  of  health. 
But  they  do  not  yield  readily  to  treatment,  and  left  to 
themselves  are  progressive,  and  show  no  tendency  to 
spontaneous  recovery. 

Treatment. — The  best  treatment  is  the  most  radi- 
cal, that  is  to  scrape  out  the  small  growths  with  the 
sharp  spoon,  to  cut  off  the  longer  small  ones  with  the 
scissors,  and  to  excise  the  large  ones.  In  any  case, 
care  must  be  used  to  get  down  to  the  true  skin  and  to 
remove  the  whole  growth.  After  removal  by  any 
means  the  base  should  be  cauterised,  and  for  this  pur- 
pose we  may  use  the  nitrate  of  silver  stick,  which  both 
cauterises  and  stops  the  sometimes  not  insignificant 
bleeding  following  the  operation.  In  some  cases  tlie 
stronger  caustics  may  be  employed  with  benefit  with- 
out operation.  Hebra,  Jr.,  (16)  speaks  highly  of  the 
galvano-cautery  in  this  disease,  and  has  found  that  it 
was  as  effectual  in  removing  the  growi;hs,  and  more 
active  in  preventing  their  return,  than  any  other  oper- 
ative procedure. 


CHAPTER  XXIY. 

N^VUS  PILOSUS. 

Hair-moles  or  birth-marks  are  usually  congenital, 
and  even  in  cases  in  which  they  have  developed  within 
a  few  years  after  birth,  the  hair  grows  upon  a  con- 
genitally    hyperpigmented     surface,     a    pigmentary 


mole.  They  are  of  all  sizes  from  that  of  a  split  pea 
up  to  that  of  a  huge  patch  big  enough  to  involve  the 
surface  of  the  body  from  a  line  betAveen  the  angles  of 
the  scapulae  to  half  way  down  the  thigh.     They  may 


N^VITS  PlLOSUS.  351 

be  unilateral  or  bilateral,  and  sometime?  symmetrical. 
There  may  be  only  one  of  them,  or  there  may  be  scores 
of  them;  and  they  may  be  located  on  any  region  of 
the  body.  It  is  when  they  are  located  on  the  face  or 
arms  that  they  come  most  often  under  our  observa- 
tion. 

Wherever  they  are  located,  and  whatever  their  size 
may  be,  they  possess  the  same  characteristics,  namely: 
upon  a  thickened  and  pigmented  patch  of  skin,  usually 
of  dark  brown  or  black  color,  there  is  a  more  or  less  lux- 
uriant growth  of  dark  stiff  hair,  and  the  whole  patch  is 
slightly  raised  above  the  level  of  the  skin,  and,  if 
large,  its  surface  is  more  or  less  uneven.  The  color 
of  the  patch  varies  with  the  complexion  of  the  individ- 
ual, being  light  brown  in  blondes,  and  dark  brown  or 
black  in  brunettes.  The  hair  is  nearly  always  darker 
upon  these  moles  than  it  is  on  the  head  of  the  same 
person,  excepting  when  the  latter  is  black.  Tlie 
amount  of  hair  present  varies  exceedingly;  sometimes 
it  is  very  luxuriant  and  grows  close  like  the  fur  of  an 
animal;  sometimes  there  are  only  a  few  stiff  hairs  in 
the  mole.  The  thick  growth  is  seen  more  often  on  the 
lai'ge  moles;  while  the  sparse  growth  is  more  common 
on  the  small  moles,  as  on  the  face.  These  hairs  are 
coarser  than  those  on  the  head;  even  when  a  hairy 
n^vus  occurs  upon  the  scalp,  the  hairs  covering  it  will 
be  coarser  than  those  about  it  Exceptionally  the  hairs 
are  fine.  Pigmentary  moles  may  or  may  not  coexist 
with  these  hairy  moles;  molluscum  fibrosum  has  been 
met  Avith  in  several  cases. 

Most  of  the  cases  reported  as  ^'circumscribed  hyper- 
trichosis "  are  examples  of  hairy  na^vi.  Some  of  these 
have  been  given  in  our  chapter  on  Hypertroi)hia  Pilo- 
rum ;  sometimes  these  moles  undergo  a  change  into 
epithehoma. 
•The  etiology  of.  npevus  pilosus  is  obscure;  our  only 


352  DISEASES   OF  THE   HAIR  AND   SCALP. 

supposition  is  that  they  are  due  to  some  nervous  influ- 
ence. At  times  they  occur  along  the  course  of  nerves, 
and  cases  of  extensive  hairy  moles  of  the  back  and 
thighs  are  not  inf  requenth^  associated  Txith  spina  bifida. 
They  are  sometimes  hereditary,  and  I  have  seen  them 
on  the  face  in  a  number  of  cases  of  facial  hirsuties. 
The  popular  idea  that  they  are  due  to  maternal  impres- 
sions received  during  pregnancy  is  supported  by  not  a 
fe^v  instances  in  ancient  and  modern  times. 

Bull  (635)  in  18S2  reported  the  case  of  a  child  with  an 
extensive  hair-mole  whose  mother  was  frightened  by 
a  dog  in  the  third  month  of  pregnancy;  and  Sommer 
(6-iO),  in  1885,  described  another  case  with  the  history 
of  the  mother  having  been  frightened  by  a  bear.  Ho^v 
far  maternal  impressions  really  influenced  these  and 
other  similar  cases  is  not  for  me  to  determine. 

HistoIogicaJJij  these  growths  consist  of  a  slight  hy- 
pertrophy of  the  papillary  layer  of  the  skin,  with  a  de- 
posit of  brown  and  black  pigment  granules  in  the  rete 
mucosum.  Morris  (2.1:.)  The  hairs  are  hypertrophied; 
the  large  hair-follicles  are  close  together  and  j^ossess 
small  accessory  hair- follicles  in  which  are  developed 
hairs;  and  there  is  a  more  rapid  fall  and  new  growth 
in  them  than  in  the  skin  of  normal  hairy  parts. 
(MiCHELSON  (^0),  in  Ziemssen.)  Chiari  (428  ap.)  found 
in  one  extensive  case  a  heaping-up  of  cells  in  the 
corium.  They  had  spindle-shaped  nuclei  and  but  little 
protoplasm.  The  papillae  were  broadened  by  the  cells. 
The  rete  appeared  thinned,  and  the  corneous  layer 
thickened.  The  hairs  were  thickened,  contained  little 
medulla,  and  stood  in  more  or  less  marked  clumps. 

The  diagnosis  of  haiiy  moles  from  cii'cumscribed 
hirsuties  is  determined  by  the  presence  of  pigmenta- 
tion and  thickening  of  the  skin  in  the  former,  and 
their  absence  in  the  latter. 

Treatment. — The  best  treatment  of  hairy  moles  is 


N^VUS  PILOSUS.  353 

electrolysis,  practised  as  taught  in  our  chapter  on  Hy- 
pertrophia  Pilorum.  This  is  an  exceedingly  brilliant 
operation  in  the  small  nsevi  of  the  face,  not  only  des- 
troying the  hair  but  also  removing  the  discoloration. 
In  large  naevi  it  will  certainly  destroy  the  hair,  and  if 
any  discoloration  remains,  it  may  be  readily  gotten  rid 
of  by  the  careful  application  of  nitric  or  acetic  acid, 
or  the  like.  Of  com'se  it  is  possible  to  remove  the  growths 
by  the  knife  or  by  powerful  caustics,  but  electrolysis  is 
a  less  painful  method,  and  if  done  with  sufficient  care  it 
will  leave  scarcely  any  scar. 


CHAPTEE  XXV. 

SYPHILIS— LUPUS — VITILIGO. 

These  Ihree  diseases  affect  the  scalp,  either  as  part 
of  a  general  eruption,  or  as  limited  to  that  region, 
alone.  When  occurring  upon  the  scalp,  their  etiology 
and  pathology  are  the  same  as  when  upon  other  regions. 
Their  symptoms  differ  slightly  from  those  seen  on  non- 
hauy  parts,  and  in  tliis  chapter  will  he  noted  only  such 
variations. 

Syphilis. 

The  erythematous,  papular,  pustular,  tubercular  and 
gummatous  forms  of  syphilis  are  met  with  on  the  scalp; 
while  the  squamous,  bullous,  vesicular,  and  pigmentary 
forms  are  not  met  with  there.  When  syphihs  attacks 
hairy  paiis  it  tends  to  assume  the  pustular  form,  the 
pustules  forming  about  the  hair-follicles;  and  this  holds 
true  during  the  whole  of  the  active  stage  of  the  dis- 
ease, or  what  has  been  named  the  secondary  period, 
whether  the  eruption  upon  the  trunk  and  extremities 
be  erythematous,  papular,  or  pustular.  Thus  Basse- 
REAU  (1),  found,  in  153  cases  of  erythematous  syphilis, 
the  scalp  affected  with  a 

Pustular  eruption,         .        .  .106  times 

Pityriasis,  .         .        .         .     13      '* 

Papular  eruption,  .         •         .       4       ^^ 

Macular        "        .         .        .         .       2      ^^ 
Noemption,  ...         .     28      '' 

Erythematous  syphilis  of  the  scalp  does  occur, 
however,  with  macules  alone,  which  here  as  elsewhere 


SYPHILIS — LUPUS— VITILIGO.  355 

are  round  or  oval,  rosy  or  red  spots,  out  of  which  the 
red  color  may  be  driven  by  pressure.  They  cause  the 
patient  no  annoyance,  and  he  would  be  ignorant  of 
their  presence  were  it  not  that  at  this  time  there  is  of- 
ten some  seborrhoea,  and  the  accumulation  of  sebaceous 
matter  about  the  mouths  of  the  hair-follicles  forms 
little  crusts  upon  which  the  comb  catches  in  combing 
the  hair.  Pustules  located  about  the  hair-follicles  are 
associated  very  often  with  the  macules,  and  the  httle 
scales  they  form  in  drying  aid  in  producing  that  symp- 
tom of  "catching  of  the  comb"  which  is  one  of  the 
diagnostic  marks  of  syphilis.  The  macular  syphilide 
of  the  scalp  is  rare,  and  is  met  with  most  often  along 
the  margin  of  the  hair  upon  the  forehead  and  occiput. 
If  it  is  accompanied  by  a  good  deal  of  seborrhoea  we 
may  have  a  marked  fall  of  the  hair  and  alopecia. 

The  Papular  syphilids  is  seen  upon  the  scalp  more 
commonly  than  the  macular  syphilide.  It  is  often  ac- 
companied by  pustular  syphilides,  and  by  seborrhoea, 
and  is  sometimes  itchy.  Its  most  frequent  site  is 
along  the  margin  of  the  hair,  and  the  papules  may  be 
either  small  or  large.  The  small  papular  syphilide  is 
round  and  slightly  elevated  above  the  surface;  red  in 
color  at  first,  afterwards  becoming  coj^pery  or  raw 
ham  colored;  in  close  relation  to  the  hairs;  and  some- 
times a  little  scaly.  It  becomes  absorbed  after  some 
weeks'  duration,  and  as  it  disapjiears  the  hair  falls  out. 
The  alopecia  is  only  partial  and  transient,  and  the  hair 
soon  gi'ows  again.  The  large  papular  syphilide  is  of 
greater  diameter  and  more  elevated  than  the  preced- 
ing variety.  Like  it,  it  is  scaly,  and  when  it  becomes 
absorbed  the  hair  falls.  This  syphilide  sometimes 
ulcerates  and  heals  with  a  cicatrix.  Sometimes  the 
papules  become  greatly  hypertrophied,  and  run  together 
to  form  raspberry-formed  masses  to  which  the  name 
of   "  framboesoid, "  vegetative,  or  verrucous  syphilide 


o56  DISEASES   OF   THE   HAIR  AND   SCALP. 

has  been  applied.  Each  mass  is  formed  of  a  number  of 
hypertrophied  papules  and  resembles  the  papillomatous 
formation  of  a  wart.  It  is  round,  of  varying  size,  and 
gives  vent  to  a  foul-smelling  secretion;  its  surface  is 
sometimes  moist  and  sometimes  crusted,  and  when  the 
crust  is  removed  a  shallow  ulcer  is  uncovered.  These 
masses  may  be  present  in  great  numbers  so  as  to  involve 
a  large  part  of  the  scalp.  They  at  last  become  absorbed 
or  break  down,  and  always  leave  permanent  baldness. 
The  Pustular  syphilide  is  very  common  upon 
the  scalp,  and  probably  occurs  in  every  case  of  syph- 
ilis with  cutaneous  manifestations.  It  is  seen  very 
early  in  the  disease  \vith  the  erythematous  eruption;  oc- 
curs also  with  the  papular  eruption;  it  may  be  part  of 
a  general  pustular  eruption,  or  may  occur  as  a  local- 
ized and  relapsing  syphilide.  The  pustules  are  either 
scattered,  or  grouped  in  circles  or  segments  of  circles, 
and  usually  occur  about  the  hair- follicles.  They  may 
be  smaU  and  superficial,  or  large,  deep  and  ulcerating; 
and  are  surmounted  by  a  greenish  or  blackish  crust 
varying  in  size,  thickness  and  color.  The  small  super- 
ficial and  pustular  syphilide  of  the  scalp,  the  acne-form 
sypliiUde,  is  seen  usually  within  the  first  six 
months  of  the  disease,  but  it  may  relapse  and  appear 
later.  It  is  a  papulo-pustular  lesion,  the  papule  appear- 
ing first  and  the  pustule  slowly  forming  on  top  of  ii. 
The  pustule  is  conical  or  shghtly  rounded  in  form,  and 
of  pin -head  size,  or  slightly  larger.  The  pustule  soon 
opens  and  discharges  its  contents,  which  dries  into  the 
characteristic  gi^eenish  crust  of  syphihs.  This  syphiHde 
is  often  very  slow  in  its  course,  especially  when  it  oc- 
curs as  a  part  of  a  general  specific  pustular  eruption,  and 
on  healing  leaves  a  small  cicatrix.  The  hair  falls  out 
of  the  folhcles  in  relation  with  the  pustules,  but  new 
hair  grows  again,  excepting  in  cases  in  which  the  dis- 
ease has  been  more  severe  than  usual,  so  that  the  deep 


SYPHILIS— LUPUS— VITILIGO.  357 

parts  of  the  hair-follicles  have  been  destroyed.  The 
pustular  syphihde  may  be  in  the  form  of  lesions  which 
are  pustules  from  the  beginning  and  tend  to  run  to- 
gether and  form  patches.  This  is  known  as  the  im- 
petigo-form sypliilide.  The  patches  are  covered  with 
greenish  or  blackish  thick  crusts;  are  evidently  made 
up  by  the  coalescence  of  several  pustules;  and  when 
the  crusts  are  removed  an  ulcerating  surface  is  ex- 
posed. The  ulceration  may  be  superficial  or  deep,  and 
in  debilitated  subjects  it  may  become  serpiginous.  This 
form  of  pustular  sypliilide  occurs  later  than  the  acne- 
form  syphihde,  usually  after  the  first  six  months;  it 
may  be  met  with  in  the  second  or  third  year  of  the 
disease.  Sometimes  it  is  apparently  the  form  in  which 
the  acne  form  of  syphilide  relapses.  Its  course  is  slow; 
it  always  heals  by  cicatrization;  and  is  always  followed 
by  permanent  baldness. 

The  third  and  last  form  assumed  by  the  pustular 
syphilide  on  the  scalp  is  called  the  ecthyma-form 
sypliilide.  This  syphilide  may  occur  during  the  second 
half  of  the  first  year,  or  be  one  of  the  late  or  tertiary 
manifestations  of  the  disease.  Occurring  early  in  the 
disease  the  pustules  may  be  very  numerous,  and  tend 
to  group;  occurring  late  in  the  disease  there  are  but 
few  of  them,  and  these  are  grouped  in  circles  or  seg- 
ments of  circles.  The  pustules  are  larger  than  the 
other  pustular  syphilides,  rapidly  become  ulcers;  and 
are  covered  soon  with  a  thick  greenish  or  brownish 
crust.  These  lesions  are  usually  superficial  in  the 
early  period  of  the  disease;  deep  and  often  serpiginous 
when  occurring  as  a  late  lesion.  The  ulcers  heal  by 
cicatrisation  and  leave  a  bald  spot. 

The  Tubercular  syphilide  is  one  of  the  late  forms 
of  syphilis,  and  occurs  sometimes  upon  the  scalp,  either 
alone  or  in  connection  with  the  same  lesion  elsewhere 
upon  the  body.     They  begin  as  deep  red  spots,  which 


358  DISEASES   OF   THE   HAIR   AND   SCALP. 

increase  in  size  and  become  elevated.  They  are  from 
a  half  to  one  inch  in  diameter;  tend  to  group  in  circles 
or  segments  of  circles;  are  sometimes  surmounted  with 
a  scale;  sometimes  ulcerate  and  become  serpiginous; 
and  sometimes  become  verrucous,  and  assume  that 
framboesoid  character  described  uiider  the  papular 
syphilide.  T\niether  ulcerating  or  not  they  leave  a 
cicatricial  spot  behind  them,  and  this  is  absolutely 
bald.  This  lesion  is  prone  to  relapse,  so  that  at  times 
a  large  part  of  the  scalp  becomes  bald. 

The  Gummatous  syphilids  is  not  very  common  on 
the  scalp.  There  may  be  only  one  gumma,  or  there 
may  be  a  number  of  them.  Small  ulcerations  fre- 
quently take  place  about  the  hair-folhcles,  so  that  the 
whole  gummatous  mass  is  covered  with  ulcers.  The 
gumma  is  either  absorbed  or  breaks  down  and  ulcer- 
ates, and  then  the  bones  of  the  skull  may  be  more  or 
less  damaged.  It  occurs  most  frequently  upon  the 
frontal  and  parietal  region,  and  causes  permanent 
baldness.  Though  these  syphilides  have  been  described 
here  as  affecting  the  scalp,  they  occui'  quite  commonly 
on  all  the  other  hairy  regions  and  then  present  similar 
symptoms.  Erysipelas  may  compHcate  syphihs  of  the 
scalp. 

The  DIAGNOSIS  of  the  early  syphihdes  is  unattended, 
as  a  rule,  with  difficulty,  other  unmistakable  symptoms 
of  constitutional  syphilis  being  present  upon  the  general 
integument.  It  is  probable  that  unless  they  cause 
baldness  they  are  frequently  overlooked.  When  ques- 
tioning a  patient,  with  some  doubtful  skin  lesion,  as  to 
his  having  had  syphilis,  the  two  most  important  facts  to 
ascertain  in  regard  to  the  scalp  are  the  occurrence  of 
baldness  in  patches  coming  on  suddenly;  and  the 
catching  of  the  comb  upon  the  little  scales  on  the 
scalp.  Sometimes  the  later  lesions  offer  considerable 
difficulty  in  diagnosis,  and  we  are  called  upon  to  deter- 


SYPHILIS— LUPUS— VITILIGO.  3i).9 

mine  whether  a  pustular  eruption  is  an  eczema,  simple 
impetigo,  or  non-specific  ecthyma,  or  a  syphilide;  or 
we  may  have  to  decide  whether  a  given  lesion  is  lupus 
or  an  ulcerating  tubercular  syphilide.  The  gumma 
resembles  a  kerion;  and  a  papular  syphilide  may  be 
mistaken  for  psoriasis. 

From  eczema  or  simple  impetigo  a  pustnlar  syphilide 
is  differentiated  by  the  history  of  the  initial  lesion  and 
preceding  specific  eruptions;  by  the  greater  slowness 
of  the  development  of  the  pustules,  and  their  not 
breaking  down  readily;  by  the  absence  of  itching  and 
burning;  by  the  greenish  or  blackish  crusts;  by  the 
little  cicatrices  left  by  the  pustules;  and  by  the  baldness 
it  causes. 

From  non-specifiG  ecthyma,  the  specific  form  may 
be  known  by  the  history  of  other  specific  lesions;  by 
the  grouping  of  its  pustules  and  their  slower  course,  by 
the  ulcers  they  form,  which  are  often  serpiginous, 
always  have  abrupt  edges,  and  are  deep,  with  their 
floors  covered  with  a  thick  puriform  fluid;  by  the 
crusts  being  thicker  and  more  heaped  up;  and  by  the 
smooth,  white,  bald  cicatrices  they  leave. 

From  lupus,  the  ulcerating  tubercular- syphilide 
differs  in  occurring  upon  the  scalp  alone  at  times, 
while  lupus  vulgaris  never  occurs  there  without  being 
found  elsewhere  upon  the  face  or  extremities;  in 
syphilis  there  is  an  entire  absence  of  the  characteristic 
brownish  nodules  or  papules  of  lupus.  Syphilitic 
ulcers  are  rounded,  often  serpiginous,  always  punched 
out  and  deep,  are  covered  with  thick,  heaped-up  green- 
ish or  blackish  crusts,  and  heal  by  a  smooth,  white, 
non-deforming  cicatrix.  Lupus  ulcers  are  more  ir- 
regular in  shape,  their  crusts  are  thinner,  and  they 
heal,  if  at  all,  with  more  or  less  puckered  and  unsightly 
^cicatrices.     SyphiHs  is  a  disease  of  adult  or  advanced 


360  DISEASES   OF   THE   HAIR  AND   SCALP. 

age,  while  lupus  is  a  disease  that  begins  most  often  in 
childhood. 

The  history  and  c^ourse  of  kerion  is  entii^ely  different 
from  that  of  a  gummatous  syphihde,  as  it  occurs  in 
childhood,  is  usually  a  single  lesion,  forms  rapidly,  is 
painful  and  tender,  and  most  often  stands  in  some  re- 
lation to  trichoph^^tosis  capitis.  A  gumma  has  a 
marked  tendency  to  break  down  and  ulcerate,  whereas 
kerion  has  no  such  disposition. 

Psoriasis  may  readily  be  distinguished  from  a  papu- 
lar syphihde  in  groups  by  the  fact  that  it  never  occurs 
on  the  scalp  alone.  It  is,  moreover,  very  decidedly 
scaly  when  upon  the  scalp,  while  the  syphihde  is  not 
scaly  though  it  may  be  crusted.  Psoriasis  causes 
neither  cicatrices  nor  baldness;  syphihs  gives  rise  to 
hoth. 

It  is  possible  that  an  epithelial  cancer  may  be  mis- 
taken for  an  ulcerating  syphihde;  but  its  hard,  waxy 
and  raised  edge,  with  dehcate  blood-vessels  running 
over  it;  its  much  slower  course;  the  shooting  pains 
that  accompany  it;  the  great  proneness  to  bleeding 
that  it  evinces;  and  the  fact  that  it  is  uninfluenced  by 
antisyphihtic  remedies,  sufficiently  estabhsh  its  diag- 
nosis. 

The  TREATMENT  of  the  syphilides  of  hairy  parts  is 
the  same  as  that  of  the  same  lesions  located  elsewhere. 
InternaUy  mercury  is  indicated  for  the  early  lesions; 
mercury  with  or  without  the  iodide  of  potassium  for 
the  intermediary  or  late  lesions;  the  iodide  of  potas- 
sium in  increasing  doses  and  pushed  rapidly  until  the 
nose  runs  and  the  eyes  water,  in  the  ulcerating  lesions. 
These  drugs,  combined  with  tonics  as  needed,  and  the 
enforcement  of  the  laws  of  hygiene,  will  enable  us  to 
effect  a  cure  of  the  disease  in  most  cases  even  ^Aathout 
local  treatment.  Local  treatment  is  demanded  to 
combat  certain  symptoms  and  to  hasten  the  disappear- 


SYPHILIS— LUPUS— VITILIGO-  361 

ance  of  the  lesions.  The  early  syphilides  usually  do 
not  require  treatment.  If  the  scalp  is  covered  with 
scabs  and  crusts  they  should  be  removed  with  soap 
and  water,  and  an  ointment  of  the  white  precipitate  of 
mercury  with  or  witliout  vaseline,  or  of  the  nitrate  of 
mercury  in  the  strength  of  one  or  two  drachms  to  the 
ounce  of  vaseUne,  may  be  applied.  If  there  are  super- 
ficial ulcerations,  the  same  ointments  may  be  used; 
and  if  the  ulcers  are  deep,  iodoform  in  powder  will 
form  a  good  dressing.  The  treatment  of  alopecia  re- 
sulting from  syphihs  has  been  given  already  in  our 
chapter  on  Alopecia. 

Lupus  Vulgaris. 

This  never  occurs  primarily  upon  the  scalp.  When 
seen  in  this  region  it  is  usually  an  extension  from  the 
forehead,  and  presents  but  a  single  patch.  It  then, 
according  to  Hans  von  Hebra  (16),  takes  the  form  of  a 
flat,  httle  elevated,  even  infiltration  of  the  skin  which 
slowly  proceeds  to  ulcerate.  The  hairs  may  grow 
with  scarcely  impaired  vigor  for  some  time  after  the 
disease  has  invaded  the  scalp.  The  disease  is  steadily 
progressive,  heals  with  cicatricial  tissue  in  one  place 
I  while  spreading  in  another,  and  in  the  course  of  years 
may  involve  the  whole  scalp,  converting  it  into  a  mass 
of  puckered  cicatrix,  which  of  course  is  without  hair. 

The  DIAGNOSIS  and  treatment  of  the  disease  as  it 
affects  the  hairy  parts  is  the  same  as  when  it  attacks 
other  parts,  and  for  this  the  reader  is  referred  to  the 
text-books  of  dermatology. 

Lupus  Erythematosus. 

This  disease  which  originates  in  the  hair-follicles 
and  the  sebaceous  and  sweat-glands  of  the  skin  is  not 
infrequently  met  with  on  the  scalp  and  hairy  parts  of 
the  body.     The  scalp  may  be  invaded  from  a  patch 


S6^  DISEASES   OF   THE   HAIR   AND   SCALP. 

upon  the  face,  or  occur  coincidentally  with  the  disease 
on  the  nose,  cheeks  or  other  parts.  It  may  occur 
upon  the  scalp  alone.  It  hegins  in  one  or  a  number  of 
round  red  spots  situated  about  the  hair-f  oUicles.  These 
increase  in  size,  and,  new  spots  appearing,  they  at  last 
coalesce  to  form  a  patch,  which  is  irregular  in  shape 
and  of  various  sizes  up  to  one  large  enough  to  involve 
the  greater  part  of  the  scalp.  A  fuUy  formed  patch 
is  of  red  or  violaceous  color,  covered  with  closely  ad- 
herent, thin,  parchment-like  scales,  which  are  attached 
to  the  follicles  of  the  scalp;  sharp  in  outhne,  always 
dry,  and  having  its  centre  formed  of  dehcate  cicatri- 
cial tissue.  EventuaUy  cicatrization  will  take  place  in 
the  whole  patch,  and  the  part  will  become  absolutely 
and  permanently  bald.  The  disease  is  slow  and 
chronic  in  its  course,  and  at  times  is  attended  with 
burning  or  itching. 

The  DIAGNOSIS  of  the  disease  is  easy.  It  is  most  apt 
to  be  confounded  with  ringworm  and  psoriasis.  Bing- 
worm  differs  from  it  in  having  a  history  of  contagion, 
III  its  rounded  shape,  in  its  abundant  scales  and  crusts, 
in  its  broken  off  and  diseased  hairs,  and  in  its  sponta- 
neous recovery  without  leaving  a  cicatrix  or  baldness. 
Psoriasis  is  distinguished  by  having  characteristic 
patches  upon  other  parts  of  the  body,  by  its  more 
abundant  scahng,  by  its  not  affecting  the  hair,  by  its 
history  of  recovery  and  relapses,  and  by  its  lea^mig  no 
cicatrix. 

The  TREATMENT  of  lupus  erythematosus  of  the  scalp 
is  the  same  as  that  of  the  same  disease  on  other  parts. 
I  would  here  only  lay  special  stress  upon  the  great 
value  of  the  local  appHcation  of  pure  carboHc  acid,  a 
plan  of  treatment  proposed  by  Dr.  Geo.  H.  Fox,  of 
New  York,  and  one  that  is  attended  with  wonderful 
results  in  many  cases.  The  acid  is  to  be  carefuUy  ap- 
phed  by  means  of  a  little  cotton  on  a  bit  of  wood,  and 
the  application  repeated  every  week,  or  more   often^ 


SYPHILIS— LUPUS — VITILIGO.  363 

the  frequency  depending  upon  the  fall  of  the  crusts 
left  by  the  previous  burning.  Cutler's  fluid  of  equal 
parts  of  carbolic  acid,  tincture  of  iodine,  and  chloral 
hydrate,  painted  on  every  four  or  five  days,  is  also 
good.  Phosphorus  in  the  dose  of  ^  to  i^  of  a  grain 
in  pill  form  may  be  administered  by  the  mouth  at  the 
same  time,  care  being  had  ta  intermit  its  use  at  inter- 
vals. 

Vitiligo. 

Leucoderma,  acquired  albinism,  or  vitihgo  often 
befalls  the  hair,  and  causes  white  patches  or  tufts  of 
hair  to  appear  among  the  darker  hair  of  the  part. 
The  skin  of  the  scalp  beneath  the  tuft  is  perfectly 
healthy,  aild  the  only  change  either  it  or  the  hair  suf- 
fers is  the  loss  of  color  on  account  of  a  loss  of  pigment. 
There  may  be  only  a  single  patch  of  white  hair,  or  there 
may  be  so  many  that  the  whole  hair  of  the  head  is 
nearly  white.  The  hair  may  be  affected  on  any  part 
of  the  body.  The  disease  is  unattended  with  symp- 
toms, and  is  chronic.  Electricity  in  the  form  of  gal- 
vanism or  in  the  static  form  offers  the  only  chance  for 
improving  the  condition,  but  that  chance  is  very  small. 
Besides  the  diseases  already  described  many  other  of 
the  cutaneous  diseases  may  occur  upon  hairy  parts,  but 
the  situation  in  no  wise  affects  the  symptoms  of  such 
diseases,  and  therefore  their  consideration  has  not  been 
included  in  this  book. 


BIBLIOGRAPHY 


Note. — References  in  the  text  (1,  2,  3,  etc.),  are  to  be  found  in 
the  following-  list  of  bibliography  and  journal  literature,  under 
the  corresponding  numbers. 

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11a.  Fournier. — LeQons  sur  la  Syphilis,  Paris. 

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66.  Michelson,  P. — Ueber  Herpes  tonsurans  und  Area  Celsi, 
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I 


BIBLIOGRAPHY.  36^ 


Canities. 


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529.  Anonymous — De  la  Teigne  Faveuse  et  de  son  Traitement 
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533.  Aubert,  P. — Role  du  Traumatisme  dans  TEtiologie  de  la 
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538.  Bulkley,  L.D.— Favus  and  its  Treatment  by  a  New  Method 
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542.  Duckworth,  D. — Case  of  Favus  of  the  Scalp  and  Bodyj, 
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544.  Fagge,  C.  H. — Remarks  on  Certain  Cutaneous  Affections, 
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545.  Fuller — Treatment  of  Favus,  Med.  Times  &  Gaz.  1857,  i. 
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546.  Gigard,  G. — Sur  une  Epidemic  de  Teigne  Faveuse  s^vis- 
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550.  Hillier— Notes  on  Skin  Diseases,  Med.  Times  &  Gaz.  1867, 
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551.  Hutchinson,  J.— Radical  Treatment  of  Favus,  Med.  Times 
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553.  Hutchinson,  J.— Clinical  Reports  on  Favus,  Med.  Times 
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555.  Jenner,  Wm. — The  Pathology  and  Treatment  of  the  Dis- 
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557.  Kaposi — Ueber  einen  Fall  von  Favus  Universalis,  Sitz- 
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558.  Knoche,  J.  P. — Favus,  The  Kansas  City  Med.  Index,  1885, 
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559.  Koser,  S.  S. — Some  Observations  upon  Favus,  Med.  & 
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560.  Laillier — Maladies  Contagieuses  du  cuir  chevelu  chez  les 
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563.  Neumann,  I.— Zur  Entwickelungsgeschichte  des  Achorion, 
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565.  Prior,  C.  E.— The  Treatment  of  Porrigo  Favosa  by  Car- 
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567.  Purser,  J.  M.— Observations  Tending  to  Show  the  Identity 
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568.  Quincke,  H.— Ueber  Favus,  Montshft.  f.  prakt.  Derm.  1885, 
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569.  Reed,  J.  C— Treatment  of  Favus,  Lancet,  1874,  ii.  365. 

570.  Remy,  Chas.— Recherches  sur  FAnatomie  Microscopique 
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571.  Reynolds,  H.  J.— Favus,  Chicago  Med.  Jour.  &  Exam.  1886, 
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572.  Sawicki— Treatment  of  Favus,  Przeglod.  lekarski  Krakow- 
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574.  Simon,  Th. — Dermatologische  Mittheilungen,  Archiv.  f. 
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585.  Bertulus.  E. — L"ecole  Moderne  et  le  Phthiriasis  ou  Maladie 
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587.  Crane,  A. — Chrisma  as  a  Parasiticide,  Lancet,  1881,  ii.  76. 

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590.  Hamal— Pediculosis  Pubis,  Med.  Times  &  Gaz.  1857,  ii.  482. 

591.  Moursou,  J. — Xouvelles  Recherches  sur  TOrigine  des 
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592.  Ryding,  Geo.— Pediculosis  Pubis,  Lancet,  1858,  i.  621. 

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594.  Rosenmever,  L. — Feber  Pediculosis  Palpebrarum,  Miinch. 
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597.  Duhring,  L.  A.— Unknown  Ova  upon  Human  Hair,  Archv. 
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604.  Chincholle — De  la  Nature  Parasitaire  du  Pityriasis  Capitis 
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606.  Ferrari— Etiology  of  Pityriasis,  Atti  Acad.  Gioencla  di  Sc. 
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608.  Heitzmann,  C. — On  the  Treatment  of  Seborrhoea,  Trans. 
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610.  Manino  Lorenzo— The  Microsporon  dispar  of  Yidal  in  Se- 
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611.  Morison,  R.  B. — A  New  Instrument  for  the  Treatment  of 
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612.  Oudemanns  &  Pekelharing — Saccharomyces  Capillitii,  ein 
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617.  Dietl — Ziir  Streitfrage  des  Weichselzopfes,  Wien.  Med. 
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018.  Hamburger — Ueber  die  Irrlehre  von  der  Plica  Polonica, 
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619.  Lessing,  F.— Plica  Polonica,  Med.  Times,  Phila.  1882-83, 
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620.  Le  Page,  J.  T.— On  ^'europathic  Plica,  Brit.  Med.  Jour. 

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622.  Mettenheimer,  C. — Zur  Entstehungsgeschichte  der  Weich- 
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624.  Urbanowicz — De  la  Plique  Polonaise,  Archv.  Gen.  de  Med. 
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XoTE. — For  literature  prior  to  1839,  see  Rosenberg,  Der  Weich- 
selzopf.  Miinchen,  1839,  pg.  65. 

Dermatitis  Papillaris  Capillitii. 

625.  Baker,  M.— Acne  Keloid,  Trans.  Path.  Soc.  Lond.  1882, 
xxxiii.  367. 

626.  Hebra,  H..  Jr. — Bericht  von  Hebra's  Klinik.  in  Wien.  fiir 
1874,  Vrtljshr.  f.  Derm.  u.  Syph.  1876,  iii.  98. 

627.  Hervouet.  H. — Xote  sur  un  Cas  d'Hypertrophie  Papilli- 
forme  du  cuir  Chevelu,  Annal.  Derm,  et  Syph.  1883,  iv,  421. 

628.  Hvde,  J.  N. — A  Clinical  Studv  of  Dermatitis  Papillaris 
Capillitii,  Jour.  Cutan.  &  Yen.  Dis.  1882,  i.  33  et  seq. 

629.  Kaposi  (Kohn) — Ueber  Sogenannte  Framboesie,  Archiv.  f. 
Derm.  u.  Syph.  1869,  i.  382. 

630.  Sangster,  A.— A  Papillary  Tumor  of  the  Scalp,  Trans.  In- 
ter. Med.  Cong.  Lond.  1881,  iii.  143. 

631.  Verita,  A.— Acne  Keloidique,  Acad.  Med.  Sc.  Mav  9th, 
1882;  Abst.  Gaz.  Med.  1882,  iv.  245. 

632.  Williams,  R.— Acne  Keloid,  Brit.  Med.  Jour.  1884,  i.  668. 

]S"aetus  Pilosus. 

633.  Anonvmous — Remarkable  Case  of  Hairv  Xaevus,  Lancet, 
1869,  ii.  276.  ' 

634.  Baker,  W.  M. — On  the  Removal,  by  Operation,  of  a  Hairy 
Mole  occupying  one-half  the  Forehead.  Lancet,  1877,  ii.  803. 

635.  BuU.'W.  A. — Case  of  Diffused  Superpigmented  Mole  of  Ab- 
domen, Brit.  Med.  Jour.  1882.  i.  304. 

636.  Despres,  A. — Heterotopic  Pileuse  Cutanee  Congenitale; 
!Xaevus  Pilosus  occupant  presque  tout  le  Corps,  Gaz.  Hebdom. 
Par.  1874.  xi.  244. 

637.  Hildebrandt,  H. — Feber  Abnorme  Haarbildung  beim 
Menschen.  Schrft.  d.  Physik.  okon.  Gslshft.  1878,  vol.  xix. 

638.  Lawson.  Geo. — Epithelioma  of  Large  Mole,  Trans.  Path. 
Soc.  Lond.  1873,  xxiv.  256. 

639.  Murrav,  Jno. — Extensive  and  Increasing  Hair  Mole  in  a 
Child,  Trans.'  Path.  Soc.  Lond.  1873.  xxiv.  257. 

640.  Sommer.  W. — Ein  Xeuer  Fall  von  Hypertrichosis  circum- 
scripta, Virchow's  Archiv.  1885,  cii.  407. 


APPEJSTDIX. 


Note. — This  appendix  is  intended  to  fill  out  the  bibliography  and 
journal  literature  of  the  diseases  of  the  hair  and  scalp  down  to  1892  in- 
clusive. 

Treatises  on  the  Skin  and  Syphilis. 

1.  Anderson,  T.  McC. — Parasitic  Affections  of  the  Skin,  London, 
1861. 

2.  Anderson,  T.  McC. — A  Treatise  on  the  Diseases  of  the  Skin,  Lon- 
don and  Philadelphia,  1887. 

3.  Brocq,  L. — Traitement  des  Maladies  de  la  Peau,  2d  Ed.,  Paris, 
1892. 

4.  Campbell,  C.  M. — Skin  Diseases  of  Infancy  and  Eaily  Life,  Lon- 
don, 1889. 

5.  Crocker,  H.  R.— Diseases  of  the  Skin,  London  and  Philadelphia, 
1888;  2d  Ed.,  1893. 

6.  Duhring,  L.  A. — Epitome  of  Diseases  of  the  Skin,  Philadelphia, 
1886. 

7.  Elchhoff,  P.  J.— Die  Hautkrankheiten,  Leipzig,  1890. 

8.  Erichsen,  J.  E.— Practical  Treatise  on  the  Diseases  of  the  Scalp, 
London,  1842. 

9.  Fox,  W.  T.— Skin  Diseases  of  Parasitic  Origin,  London,  1863. 

10.  Fox,  T.  and  T.  C. — Epitome  of  Skin  Diseases,  London  and  Phila- 
delphia, 1883. 

11.  Friese,  C— Haut  und  Haare,  Berlin,  1891. 

12.  Hardaway,  W.  A.— Manual  of  Skin  Diseases,  Philadelphia,  1891. 

13.  Hardy,  A  — Traite  des  Maladies  de  la  Peau,  Paris,  1886. 

14.  Hunt,  T. — Pathology  and  Treatment  of  Certain  Diseases  of  the 
Skin,  London,  1847. 

15.  Jackson,  G.  T.— Ready- reference  Handbook  of  Diseases  of  the 
Skin,  Philadelphia,  1892. 

16.  Jamleson,  W.  A. — Diseases  of  the  Skin,  3d  Ed.,  Philadelphia  and 
Edinburgh,  11-92. 

17.  l\aposi,  M. — Pathologic  et  Traitement  des  Maladies  de  la  Peau, 
ed.  Besnier  et  Doyon,  Paris,  1891. 

18.  Keyes,  E.  L. — Genito-Urinary  Diseases  with  Syphilis,  New  York, 
1888. 

19.  Kippax,  J.  R. — Handbook  of  Diseases  of  the  Skin,  Chicago,  1884. 

20.  Klencke,  H. — Dietetische  Kosmetik,  Leipzig,  1888. 

21.  Kopp,  C. — Die  Trophoneurosen  der  Haut,  Wien.  1886. 

22.  Leloir  et  Vidal. — Traite  descriptif  des  Maladies  de  la  Peau,  Paris, 
1889,  et  seq. 

23.  Liveing,  R. — Handbook  of  Skin  Diseases,  London,  1887. 

24.  Morris,  M.— Management  of  Skin  and  Hair,  London, 


392  APPENDIX. 

25.  Neumann,  C.   E.  O.— Die  Haut,   Hjiare,   Nagel  und  Zahne  des 
Meuschen,  Leipzig. 

26.  Olimanu-Dumesnil,  A.  H.— Handbook  of  Dermatology,  St.  Louis, 
18^9. 

27.  Piffard,  H.  G. — Practical  Treatise  on  Diseases  of  the  Skin,  New 
York,  189L 

28.  Pvavogli,  A.— The  Hygiene  of  the  Skin,  Cincinnati,  1888. 

29.  Rohe,  G.  H.— Practical  Manual  of  Diseases  of  the  Skin,  Philadel- 
phia, 1892. 

30.  Schultz,  H.— Haut,  Haare  und  Nagel,  Leipzig.  1885. 

31.  yhoemaker.  J.  V. — Practical  Treatise  on  Diseases  of  the  Skin, 
2d  Ed.,  New  York.  Ib92. 

32.  Startin,  J. — Lectures  on  Parasitic  Diseases  of  the  Skin,  London, 
18!il. 

33.  Stelwagon,  H.  W.— Essentials  of  Diseases  of  the  Skin,  Philadel- 
phia, 1890. 

3i.  Van  Harlingen,  A.— Handbook  of  Skin  Diseases,  2d  Ed.,  Phila- 
delphia 1889. 

Treatises  on  the  Hair. 

35.  Audrain,  I. — Contribution  a  TEtude   de  la  Trichophytie  tonsu- 
rante,  These  de  Paris,  lb92. 
3(5.  Barteau,  P.  A.— De  la  Teigne  tonsurante,  These.  Paris,  1856. 

37.  Bchr,  Th.  and  E. — Das  neue  Haarerzeugungsverfahren,  Leipzig. 

38.  Bernhardt,  H  — De  Sycosi,  Berlin,  1862. 

39.  Beschoruer,  F. — Der  Weichselzopf,  Breslau,  1843. 

40.  Besnier.  E.— Sur  la  Pelade,  Paris,  18^8. 

41.  Blumenthal,  B. — Ueber   Sycosis  vulgaris  et  parasitaria,   Darm- 
stadt, 1886. 

42.  Boeck,  F.— Ueber  die  Area  Celsi,  Greifswald,  1867. 

43.  Bondi,  E.— Pathologic  des  Weichselzopfs,  Berlin,  1828. 

44.  Braschoss,  J. — Merkwlirdige  Fiille  von  Favuserkrankung,  Bonn, 
1887. 

45.  Braunstein.  H. — Ueber  Alopecia  areata,  Freiburg,  1873. 

46.  Buchiu,   M.— De  la  Pelade  :  Nature,   Traitement,   Prophylaxie, 
Paris,  1887. 

47.  Bulkley,  L.  D.— Acne  and  Alopecia,  Detroit,  1892. 

48.  Burnett,  J,  C. — Ringworm:  its  Constitutional  Nature  and  Cure, 
Loudon,  1892. 

49.  Cantani,  A. — Un  Caso  de  Atrofia  progressiva,  Napoli,  1887. 

50.  Carrere,  G.  A. — iLl\i6e  sur  le  Traitement  de  la  Teigne  toudante, 
Paris,  1890. 

51.  Churlet,  M.— Dissertation  sur  la  Teigne,  Strasbourg,  1811. 

52.  Claudat,  F.  N.— De  la  Teigne  et  de  son  Traitement,  Paris,  1879. 

53.  Clemenceau. — La  Pelade,  Nantes,  1891. 

54.  eleven,  K.— Die  Haarkur.  Berlin,  1891. 

55.  Feiertag,  I. — Ueber  die  Bildung  der  Haare,  Dorpat,  1875. 

56.  Geyl. — Beobachtungen  und  Ideen  iiber  Hypertrichose,  Hamburg 
und  Leipzig,  1890. 

57.  Goossens,  L  C.  H. — Over  Area  Celsi,  Rotterdam,  1885. 

58.  Grenier,  J.  N. — Essai  sur  la  Teigne,  Strasbourg,  1810. 

59.  Gurney,  Thos. — Specific  Disease  a  Cause  of  Baldness,   London, 
1888. 

60.  Hamburger,  E. — Ueber  die  Trrlehre  von  der  Plica  polonica,  Ber- 
lin, 1861.      ' 


APPENDIX.  393 

61.  Hayes,  P.  S. — Electricity  and  the  Methods  of  its  Employment  ia 
the  Removal  of  Superfluous  Hair,  etc..  Chicago,  1889. 

62.  Hennocque,  C— Du  favusde  la  Peau  et  des  Muqueuses,  ThSse, 
Paris,  1885. 

63.  Kaeseler,  G.— Ueber  Area  Celsi  seu  Alopecia  areata,  Greifswald, 
1886. 

64.  Kruska,  E. — Ein  Beitrag  zu  dem  Kapitel  :  Abnorme  Behaarung 
beim  Menschen,  Jena,  1890. 

65.  Landau,  C. — Ueber  Sycosis  parasitaria,  Bonn,  1885. 

66.  Lanoix. — Beobachtungen  liber  die  mit  dem  Abschneiden  der 
Haare  verbundene  Gefahr,  179-. 

67.  Lettre,  M.  D.— Ueber  Plica  oder  Zopfkrankheit.  Berlin,  1870. 

68.  Loriot,  G.— Contribution  a  I'Etude  de  la  Pelade,  Paris,  1887. 

69.  Marcus,  M. — Ueber  Alopecia  areata,  Bonn,  1886. 

70.  Marianelli,  A. — Achorion  Schoenleinii,  Pisa,  1893. 

71.  Muret-Deperet. — De  la  Folliculite  conglomeree  trichophytique, 
ThSse  de  Paris,  1892. 

72.  Nachtigal. — Ueber  Area  Celsi,  Wlirzburg,  1885. 

73.  Nollet,  H.  C. — liiudes  sur  la  Nature  de  la  Pelade,  Bordeaux, 
1888. 

74.  Reissner,  E. — Beitriige  zur  Kenntniss  der  Haare  des  Menschen 
und  der  Siiugethiere,  Breslau,  1854. 

75.  Richard,  J. — De  la  Teigne  faveuse,  Neucbatel,  1859. 

76.  Richter,  W.— Ueber  Area  Celsi,  Wlirzburg,  1884. 

77.  Romisch,  W. — Ueber  Favus  und  Favusbehandlung,  Freiburg, 
1891. 

78.  Rothenberg,  J.— Der  Weichselzopf,  Wlirzburg,  1841. 

79.  Rowland,  A. — The  Human  Hair,  London,  1853. 

80.  Sommerfeld.  T. — De  Ziekten  van  het  Huar,  Amsterdam,  1891. 

81.  Thin,  Geo. — Pathology  and  Treatment  of  Ringworm,  London, 
1887. 

82.  Wollermann,  T,— Ueber  Plica  poionica,  Berlin,  1868. 

JOURNAL    LITERATURE. 
Anatomy  and  Physiology. 

83.  Duclert,  L. — Determinisme  de  la  frisure  des  productions  pileuses, 
Jour.  d.  TAiiat.  et  Phys.,  1888,  xxiv.,  103. 

84.  Foley,  J.  L.— The  hygiene  of  the  hair,  N.  Y.  Med.  Jour.,  1887, 
xlv.,406. 

85.  Garcia,  R. — Beitrage  zur  Kenntniss  der  Haarwechsels  bci  mensch- 
lichen  Embryonen  und  Neugeborenen,  Abst.  Montshft.  f .  prkt.  Der- 
mat.,  1892,  xiv.,  242. 

86.  Giovannini,  S. — Ueber  die  normale  Entwicklung  und  iiber  einige 
Veranderungen  der  menschlichen  Haare,  Vrtljhr.  f.  Derm.  u.  Syph., 
1887,  xiv.,  1049. 

87.  Giovannini,  S. — De  la  regeneration  des  poils  apr^s  I'epilation, 
Arch.  Mikros.  Anat.,  1890,  xxvi.,  528. 

88.  Giovannini,  S. — Delle  alterazione  dei  follicoli  nella  depilazione, 
etc.,  Giorn.  ital.  d.  mal.  ven,,  etc.,  1890,  xxv.,  378. 

89.  Giovannini,  S. — Sur  la  keratination  dii  poil  et  les  alterations  des 
follicules  causees  par  I'epilation,  Arch,  de  Biologic,  1890,  x.,  609. 

90.  Giovannini,  S. — Ueber  ein  Zwillingshaar  mit  einer  einfachcu 
Wiirzelscheide,  Arch.  Derm.  u.  Syph.,  1893,  xxv.,  187, 


394  APPENDIX. 

91.  Mertsching,  A. — Beitrage  zur  Histologie  des  Haares  und  Haar 
balges,  Archiv.  Mikros.  Anat.,  1887-8.  xxxi.,  32. 

92.  Recker,  H. — Eiue  Nachlese  zu  Erdls  und  Waldeyers  Untersuch- 
ungen  liber  die  Haare,  Jahrsbrcht.  d.  Westfalischen  Prov.-Vereins, 
Mimster,  1891,  xix. 

93.  Schein.  M. — Ueber  das  Waclisthum  der  Haiit  und  der  Haare  des 
Menschen,  Wien.  kliu.  Woch.,  1892,  v.,  86;  Arch.  Derm.  u.  f  yph., 
1892,  xxiv.,  429. 

94.  Schweninger,  E. — Ueber  Transplantation  und  Implantation  von 
Haaren,  (his  works)  1886,  i.,  1. 

95.  Sewell,  H. — The  cleansing  functions  of  hairs,  Science,  1893, 
xxi.,  117. 

96.  Stieda,  L.— Ueber  den  Haarwechsel,  Biol.  Centrlbl.,  1887-8,  vii., 
353.  et  seq. 

97.  Veraglia  ed  Conti. — Contribute  alio  Studio  delle  ghiandolo 
cutanee  e  dei  foUicoli  piliferi,  Giorn.  del.  R.  Acad,  di  Med.  di  Torino, 
1885  (abst.  Monatshft.  f.  prkt.  Dermat.,  1887,  vi.,  720). 

Bonnet.— Morpholoe:.  Jahrb.,  1885-0,  xi.,  220;  Sitzungsb.  d.  phys.  med. 

Gslschft.  z.  Wiirzb.,  l'<8!t.  129. 
Hoffmann,  L  —Deutsche  Zeitschr.  f.  Thiermed.,  1885-6,  xii.,  51. 
Maurer,  F— Morphol  Jahrbuch.,  1891-*^,  xvi.i.,  7l7. 
Topinard,  P.— Rev.  d'Anthrop  ,  1887,  ii.,  1 
Voigt,  C.  A.— Denkschrif t  d.  K.  Akad.  d.  Wissenschaft.  Ed.  xiii. 

Canities. 

98.  Breda,  A. — (Ringed  Hair)  Rivista  Veneta  di  Scienze  mediche; 
abst.  Montshft.  f,  prkt.  Dermat.,  1888,  vii.,  291. 

99.  Falkenheim,  H. — Zur  Lehre  von  den  Anomalien  der  Haarfarbung, 
Vrtljhr.  f.  Dermat.  u.  Syph.,  1888,  xv.,  33. 

100.  Lesser,  E. — Ueber  Ringelhaare,  Tagebl,  d.  Versamml.  deutsche 
Katurforsch.,  etc.,  18d5,  Iviii.,  160;  also  Ann.  Derm.  et.  Syph.,  1886, 
vii.,  36. 

101.  Lesser,  E. — Ein  Fall  von  Ringelhaaren,  Vrtljhr.  f.  Derm.  u. 
Syph.,  1886,  xiii.,  51. 

102.  Morgan,  J.  H.— Hereditary  tuft  of  white  hair  on  the  forehead, 
Brit.  Med.  Jour.,  1890,  ii  ,  85. 

103.  Robinson,  T. — Lalduess  and  grayness,  Wood's  Med.  and  Surg. 
Monog.,  1891,  ix.,  725. 

Obolonski,  N.— Sborn.  rabat  Charkoflf.,  1886-7,  ii.,  74. 

Ottolenshi.— Arch  di  priehiat.  Torino,  1.S89,  x.,  194. 

SchuUe,  J.  C— Vrhndl.  d.  Berl.  Gesellshft.  f.  Anthrop.,  1886,  p.  559. 

Discoloration  of  the  Hair. 

104.  Prentiss,  D.  W. — Change  of  color  in  the  hair  from  the  internal 
use  of  pilocarpin,  Trans.  X.  Int.  Med.  Cong.,  1891,  iv.,  24. 

Alopecia. 

105.  Anonymous. — Therapie  der  Alopecia  pityrodes,  Montshft.  f. 
prkt.  Dermat.,  1888,  vii.,  295. 

106.  Arnozan,  H. — Folliculites  depilantes  des  parties  glabres,  Ann. 
Derm,  et  Syph.,  1892,  iii.,  491. 

H»7.  Besnier,  E. — Alopecie  cicatricielle  innominee,  Ann.  Derm,  et 
Syph.,  1888,  X.,  104, 


APPENDIX.  395 

lOS.  Blaschko  —Alopecia mit Trichorrhexis, Montshft.  f.  prkt.  Derm., 
1891,  xiii.,  105. 

109.  Brocq,  L. — Des  folliculites  et  perifolliculites  decalvantes,  Bui. 
etMem.  Soc.  Med.  et  Mem.  Hop.  de  Par.,  18S8,  v.,  399. 

110.  Brocq.  L. — Treatment  of  alopecia  syphilitica,  Jour.  Cut.  and 
Gen.-Urin.  Dis.,  1889,  vii.,  346. 

111.  Brocq,  L. — Des  rapports  qui  existent  entre  les  aloperies  de  la 
keratose  pilaire  et  les  alopecies  dites  seborrhtique,  Ann.  Derm,  et 
Syph.,  1893,  iii.,  773. 

113.  Carrier,  A.  E.— Bald  heads,  Trans.  Mich.  Med.  Soc,  1891,  xv., 
106. 

113.  Curtis,  R.  J.— Brains  or  hair,  Med.  Rec,  1886,  xxx.,  526. 

114.  Darier. — Sur  I'examen  microscopique  descheveux  dans  Talopecie 
syphilitique,  Ann.  Derm,  et  Syph.,  1889,  x.,  198. 

115.  De  Molines,  P. — Sur  uu  cas  d'alopecie  congenitale,  Ann.  Derm. 
etSyph.,  1890,  i.,  54. 

116.  Elliot,  Geo.  T. — Alopecia  praematura  :  its  most  frequent  cause, 
seborrhoeal  eczema,  N.   Y.  Med.  Jour  ,  189;{,  Ivii.,  130. 

117.  Ferros. — Beitrag  zum  Studium  der  Alopecie,  Montshft.  f.  prkt. 
Dermat.,  1893,  xiv.,  528. 

118.  Fournier,  A  — De  alopecies,  Med.  Modern.,  1889-90,  i  ,  957. 

119.  Fournier,  A. — L'alopecie  syphilitique,  Union  med.,  1890,  l.,793; 
Gaz.  med.  de  Par.,  1888,  v.  49. 

130.  Giovannini  — (Anatomical  Changes  in  Alopecia  areata  and  Alo- 
pecia syphilitica)  abst,  Montshft.  f.  prkt.  Dermat.,  1888,  vii  ,  28. 

131.  Giovannini. — (Alopecia  syphilitica)  Arch.  Derm.  u.  Syph,  1893, 
xxiv.,  1033. 

133.  Gouinlock,  "W.  C. — Hats  as  a  cause  of  baldness.  Pop.  Sc.  Month., 
1887,  xxxi.,97. 

133.  Graetzer,  E. — Die  Lassar'sche  Haarkur  in  der  Privatpra.xis, 
Therap.  Montshft.,  1889,  iii.,  453. 

134.  Holder,  A.  B. — Diseases  among  Indians,  Med.  Rec,  1893,  xlii., 
357. 

135.  Hyde,  J.  K— Congenital  alopecia,  Internat.  Clinics,  1891.  i  ,  321. 
126.  lUingworth.— Tinea  decalvans,  Brit.  Med.  Jour.,  1S91,  ii  .  457. 

137.  Jackson,  G.  T. — A  practical  treatise  on  baldness.  Wood's  Med. 
and  Surg.  Monographs,  1889,  iv.,  GOl. 

138.  Jackson,  G.  T.— Baldness  :  what  can  we  do  for  it  ?  Med.  Rec, 
1887,  xxxi.,  509. 

129.  Jardit,  P. — Observation  d'alopecie  du  cuirchevelu  et  de  labarbe, 
etc..  Ann.  Derm,  et  Syph.,  1891,  ii.,  461. 

130.  Lassar,  O.— Ueber  Haarkuren.  Therap.   Montshft.,  1888,  ii.,  543. 

131.  Mapother. — Alopecia  symptomatica,  Brit.  Med.  Jour  ,  July  5th, 
1891. 

133.  Mayerhausen,  G.— Die  franklinische  Kopfdouche  als  mittels 
gegen  das  Ausfallen  der  Haare,  Int.  kiln.  Rundschau,  1890,  iv. ,  1841. 

133.  O'Neil,  W.— Rejuvenescence  of  hair  of  head  and  beard,  18S9,  ii., 
113. 

134.  Paschkis,  H.— Traitement  de  l'alopecie  d'origine  seborrheique, 
Nouv.  Montpelr.  med.,  October  8th,  1893,  J.  d.  ]\lal.  cut.  et  Syph., 
1893,  iv.,  667. 

135.  Paschkis.  H.— Die  Therapie  des  Haarausfalles,  Centrlbl.  f.  d. 
ges.  Therap.,  1893,  x.,  321. 

136.  Quinquaud. — Folliculite  epilante  decalvante,  Ann.  Derm,  et 
syph.,  1889,  x.,  99. 


596  APPE>T)IX. 

137.  Robinson,  T. — Baldness  and  grayness,  Wood's  Med,  and  Surg. 
Monographs,  1891,  ix  ,  725. 

13S.  Schultz,  F.  J.  -Atrichia  adnata,  Vrhndl.  der  Rigaer  Gesellsch. 
deutsch.  Aerzte.  1891  ;  ref.  Montshft.  f.  prkt.  Derm  ,  1893,  xvi.,  242. 

139.  Semeleder,  F. — Congenital  baldness,  Med.  Rec,  1888,  xxxiii., 
441. 

140.  Tyson,  W.  J. — Some  remarks  on  premature  baldness,  Lancet, 
1891,  ii.,  173. 

141.  Unna,  P.  G. — (Successful  inoculation  of  alopecia  pitvrodes) 
Montshft.  f.  prkt.  Derm.,  1892,  xiv.,  413. 

142.  Ward,  E.  B.— Baldness:  what  shall  we  do  with  it  ?  Med.  Age, 
1887,  v.,  391. 

143.  Wheeler.  G.  H.— About  bald  heads,  New  York  Evening  Post, 
Auffust  6th,  18-7. 

144.  White.  A.— Alopecia  adnata.  Med.  Age.  1887,  v.,  318. 

145.  Wickham,  L. — An  undescribed  form  of  alopecia,  Brit.  Jour, 
Dermat.,  1888-9,  i.,  227. 

Alopecia  Areata. 

146.  Arnozan,  X. — Pseudopelade  avec  plaques  achromateuses  et 
plaques  hyperchromateuses,  Bui.  Soc.  Fran9.  d.  Dermat.,  1891,  ii.,  352. 

147.  Askanazy,  S. — Casuitisches  zur  Frage  der  Alopecia  neurotica, 
Arch.  Derm.  u.  Syph.,  1890,  xxii..  523. 

148.  Barthelemy. — Pelade  geueralisee  au  cuir  chevelu  et  ^  la  face, 
traitee  par  le  procede  du  Dr.^Moty,  Bui.  Soc.  Fran9,  d,  Dermat.,  1891, 
ii.,  421,443. 

149.  Barthelemy. — Pelade  traitee  par  les  injections  intradermiques  de 
sublime.  Ann.  Derm,  et  Syph.,  1892,  iii.,  1165. 

150.  Behrend,  G. — Ueber  die  klinischen  Grenzen  der  Alopecia  are- 
ata, Berl.  klin.  Woch.,  1887,  xxiv.,  108. 

151.  Behrend.  G. — Ueber  Alopecia  areata  und  iiber  die  Veranderun- 
geu  der  Haare  bei  derselbeu.  Arch.  path.  Anat..  1887,  cix,,  493, 

152.  Belirend,  G. — Zur  Frage  von  der  Alopecia  areata,  Berl.  klin. 
Woch.,  1888,  XXV.,  148. 

153.  Buhrend,  G. — Ueber  Nervenliision  und  Haarausfall  mit  Bezug 
auf  der  Alopecia  areata.  Arch.  path.  Anat.,  ]8'*'9,  cxvi.,  173, 

154.  Besnier,  E— Instruction  provisoire  sur  les  mesures  a  prendre  a 
regard  des  sujets  atteints  de  pelade,  Trib.  med.,  1^89,  xx.,  410. 

155.  Blaschko,  A.— Vor-stelluno:  eines  Falles  von  Alopecia  areata, 
Berl.  klin.  Woch.,  1891,  xxviii.,  1152. 

156.  Blaschko,  A. — Alopecia  areata  und  Trichorrhexis,  Berl.  klin. 
Woch.,  1892,  xxix.,  71  ,  Trans.  Ann,  Derm,  et  Syph.,  1892,  iii.,  211.^ 

157.  Brocq,  L. — Doit  on  considerer  la  pelade  comme  une  affection 
contagicuse,  Gaz.  hebdom.,  1887,  xxiv..  307. 

158.  Brousse. — Un  cas  de  pelade  totale  du  cuir  chevelu,  Bui.  Soc. 
Fran9.  de  Dermat.,  1891,  ii.,  195. 

159.  Bulkley,  L.  D.— Clinical  studv  on  alopecia  areata  and  its 
treatment,  Trans.  Med.  Soc.  N.  Y.,  1889,  184  ;  Med.  Rec,  1889,  xxxv., 
231. 

160.  Bulklev,  L.  D, — A  therapeutic  note  on  alopecia  areata,  Jour. 
Cut.  and  Gen.'-Urin.  Dis.,  1892,  x.,  47. 

161.  Busquet,  G.  P. — Du  traitement  antiseptic^ue  des  teignes  et  en 
particulier  de  la  pelade,  Ann.  Derm,  et  Syph.,  1892,  iii.,  269. 

162.  Chatelain,  E. — Du  traitement  de  la  pelade  par  le  collodion  iode, 
J.  d.  Mai.  cutan.  et  syph.,  1890-1,  ii.,  221. 


Appendix.  397 

163.  Chatelain,  E. — Nouvelles  observations  sur  le  traitement  de  la 
pelade  par  le  collodion  iode,  J.  Mai.  cutan.  et  syph.,  1891,  iii.,  (505. 

164.  Crocker,  H,  R. — Alopecia  areata  :  its  pathology  and  treatmeot, 
Lancet,  1891,  i.,  478. 

165.  Crocq,  J. — Ueber  Wechselseitige  Beziehungen  von  Alopecia 
areata,  Psychosen,  und  Spermatorrhoea,  Presse  med.  Beige,  1892, 
No.  xiv. 

166.  Cutler,  C.  W. — The  use  of  iodine,  carbolic  acid,  and  chloral  in 
dermatology.  Jour.  Cut.  and  Gen.-Urin.  Dis.,  1892,  x.,  380. 

167.  De  Tullio. — (Progressive  areaform  atrophy  of  hair  follicles) 
Rif.  Med.,  18S7  ;  Montshft.  f.  prkt.  Dermat.,  1887,  vi.,  769. 

168.  Eichhoff,  P.  J.— Zur  Frage  der  Kontagiositiit  der  Alopecia  are- 
ata, Montshft.  f.  prkt.  Dermat.,  1888,  vii.,  1025. 

169.  Ferros. — Contribution  au  traitement  de  la  pelade,  Annal.  Soc. 
d'Hydrol.  med.  Par.,  1892,  xxxvii.,  249  ;  Ann.  Derm,  et  Syph.,  1892, 
iii..  546. 

170.  Feulard,  H. — La  favus  et  la  pelade  en  France,  Ann.  Derm,  et 
Syph.,  1892,  iii,  1118. 

171.  Feulard,  H.— Pelade  decalvante  et  vitiligo,  Ann.  Derm,  et 
Syph.,  1892,  iii.,  842. 

172.  Fournier,  H. — La  recrudescence  de  la  pelade.  Jour,  de  Med. 
Par.,  1888,  xv.,  35. 

173  Froelich,  L.— Pelade  et  lesions  oculaires,  Rev,  med.  de  la  Suisse 
Romande,  1890,  x.,  745. 

174.  Froelich,  L. — Ueber  Augenerkrankung  bei  Alopecia  areata, 
Berl.  klin.  Woch.,  1891,  xxviii.,  343. 

175.  Giovannini,  S. — (Anatomical  changes  in  alopecia  areata,  etc.) 
abst.  Montshft.  f.  prkt.  Derin.,  1888,  vii.,  28. 

176.  Giovannini,  S. — Recherches  sur  I'histologie  palhologique  de 
la  pelade,  Ann.  Derm,  et  Syph.,  1891,  ii.,  921. 

177.  Giovannini,  S. — Ueber  die  histologischcn  Venlnderungen  der 
syphilitischen  Alopecie  und  ihr  Verhilltniss  zu  den  Verilnderuugen  der 
Alopecia  areata,  Montshft.  f.  prkt.  Dermat.,  1893,  xvi.,  157. 

178.  Griudon,  J. — Etiology  of  alopecia  areata,  Wkly.  Med.  Rev., 
1889,  XX.,  381. 

179.  Hallopeau,  H. — Sur  une  nouvelle  variete  d'angionevrose  don- 
nant  lieu  a  la  plaques  d'alopecie  pseudo-peladique,  Bui.  Soc.  Fran9.  de 
Dermat..  1891,  ii.,  157. 

180.  Hallopeau,  H. — De  la  nature  de  la  pelade  et  des  antiseptiques 
propres  a  son  traitement,  Union  med.,  1889,  xlviii.,  337. 

181.  Havenith,  Dubois. — La  policlinique,  Brux.,  1892,  No.  10. 

182.  Hoffmann  R. — Ein  Fall  von  Alopecia  areata  nficli  Trauma, 
Allg.  Med.  Centrl.-Ztg.,  1889,  Iviii.,  1361;  Maryland  Med.  Jour.,  1889- 
90,  xxii.,  344. 

183.  Hutchinson,  J. — Alopecia  areata  usually  a  sequel  of  ringworm, 
Arch.  Surg.,  1889-90.  i.,  162. 

184.  Hutchinson,  J. — The  permanency  of  cures  in  alopecia  areata, 
Arch.  Surg.,  1889-90,  i.,  163. 

185.  Hutchinson,  J. — Universal  alopecia  in  middle  age  with  history 
of  severe  ringworm  in  childhood,  Arch.  Surg.,  1889-90,  i.,  370. 

186.  Hutchinson,  J. — On  alopecia  areata  and  its  relation  to  ring- 
worm, Arch.  Surg.,  1893,  iv  ,  289. 

187.  Joseph.  M. — Zur  Aetiologie  der  Alopecia  areata,  Centrlbl.  f.  d. 
med.  Wissenschft.,  1886,  xxiv.,  178. 

188.  Joseph,  M. — Experimentelle  Untersuchungen  iiberdie  Aetiologie 
der  Alopecia  areata,  Wien.  med.  Woch.,  1886,  xxxvi.,  1642. 


398  APPENDIX. 

189.  Joseph,  M. — Zur  Aetiologie  und  Symptomatik  der  Alopecia 
areata,  Berl.  klin.  Woch.,  1888,  xxv.,  82,  etc. 

190.  Joseph,  M — Erwiderung  auf  Herrn  Dr.  G.  Behrend's  Aufsatz, 
etc.,  Arch.  path.  Anat..  1889,  cxvi.,  333. 

191.  Kaposi,  M. — Alopecia  areata  oder  Area  Celsi,  Internat,  klin. 
Rundschau,  1889.  iii.,  536. 

192.  Kinney,  Thos.  H. — Alopecia  from  nervous  shock,  Yirg.  Med. 
Month.,  1880^81,  vii.,  937. 

193.  Lavallee,  A.  Morel. — Sur  un  mode  de  traitement  rapide  de  la 
pelade,  etc..  Union  med..  1892,  liii.,  889  ;  Ann.  Derm,  et  Syph.,  1892, 
iii..  713;  Bull.  Soc.  Fr.  Derm.,  1892,  iii.,  318. 

194.  Leloir,  H. — De  la  pelade  et  des  peladoi'des,  Bull.  Acad.  Med. 
Par.,  1888,  xix.,  936;  Gaz.  Hop.,  1888,  Ixi.,  700. 

195.  Leo. — Ein  Fall  von  Alopecia  areata,  Monlshft.  f.  prkt.  Derm., 
1887,  vi.,  1119. 

196.  Lewinski. — Ein  eigenartiger  Fall  von  Verlust  des  Kopfhaares, 
Montshft.  f.  prkt.  Dermat^,  1887,  vi.,  141. 

197.  Merklen,  P. — Etiologie  et  prophylaxie  de  la  pelade,  Ann.  Derm. 
etSyph.,  1888,  ix.,  813. 

198.  Mibelli.  V.— Sulla  patogenesi  dell'  Alopecia  areata,  Giorn.  ital. 
d.  Mai.  ven.,  188S,  xxix.,  416. 

199.  Mibelli,  V". — (Alopecia  areata)  Boll.  n.  r.  Accad.  d.  fis.  di 
Sienna,  1887,  v.,  63  (abst.  Montshft.  f.  prkt.  Dermat.,  1887,  vi.,  629). 

200.  ;^[orrow,  P.  A. — The  treatment  of  alopecia  areata,  Jour  Cut, 
and  Gen.-Urin.  Dis.,  1891,  ix.,  381. 

201.  Motv.— Xouveau  traitement  de  la  pelade,  Ann.  Derm,  et  Syph., 

1891,  ii..  406,  864. 

202.  Nachtigal. — Ueber  das  Yerhalten  der  electrocutaneous  Sensibilitat 
bei  Area  Celsi.  Mitth  a.  d.  med.  Klin.  z.  Wurzb.,  1886,  ii.,  405. 

203.  xsimier,  H.  — De  la  folliculite  microbienne  tonsurante  du  cuir 
chevelu,  Gaz.  hebdom.,  1890,  xxvii.,  234. 

204.  Ohmann-Dumesnil,  A.  H. — A  case  of  alopecia  areata  due  to 
traumatism,  Tr.  Med.  Assoc.  Missouri,  1889,  p.  144;  St.  Louis  Clin. 
Phys.  and  Surg.,  1890,  iii.,  104. 

205.  Ohmann-Dumesnil,  A.  H.— Some  successful  methods  of  treat- 
ing alopecia  and  alopecia  areata.  N.  O.  Med.  and  Sura:.  Jour.,  1892, 
XX.,  1;  Med.  News,  1892,  Ixi.,  146;  Monatshft.  f.  prkt. '^Dermat.,  1892, 
XV.,  49. 

206.  Ollivier,  A.— La  pelade  et  lecole,  Bul.  Acad.  Med.  Par.,  1887, 
xviii..  725;  Rev.  de  Hygiene,  1887,  ix.,  195. 

207.  Overall,  G.  W. — Alopecia  the  result  of  lesions  of  trophic 
nerve  centres,  Alienist  and  Xeurol.,  1886,  vii.,  254. 

208.  Petrini. — Note  sur  uu  cas  de  calvitie  et  de  pelade  generalisee, 
Bul.  Soc.  Fr.  Derm,  et  Svph.,  1892,  iii.,  250;  Ann.  Derm,  et  Syph., 

1892,  iii.,  554. 

209.  Pontoppidan,  E. — Ein  Fall  von  Alopecia  areata  nach  Operation 
am  Halsen,  Montshft.  f.  prkt.  Dermat.,  1889,  viii.,  51. 

210.  Putnam,  C.  P.— An  epidemic  of  baldness  in  spots  (alopecia 
areata  ?)  in  an  asylum  for  srirls.  Arch.  Pediat.,  1892,  ix.,  595. 

211.  Queely,  E.  St.  G.— Alopecia  areata,  Lancet,  1887,  ii.,  1266. 

212.  Quinquaud. — De  la  pelade,  Semaine  med.,  1890,  x.,  301. 

213.  Raymond,  P. — Considerations  sur  le  traitement  de  la  pelade, 
Bul.  Soc.  Fr.  Derm,  et  Syph.,  1892,  iii.,  386;  Ann.  Derm,  et  Syph., 
1892,  iii.,  794. 

214.  Raymond,  P. — Les  nouveaux  traitements  des  peladiques,  Gaz.  d. 
Hop.,  1892,  Ixv.,  893. 


APPENDIX.  899 

215.  Robinson,  A.  R. — The  pathology  and  treatment  of  alopecia 
areata,  Trans.  IX.  Inter.  Med.  Cong.,  18»7,  iv.,  241;  Moutshft.  f.  prkt. 
Dermat.,  1888,  vii.,  476. 

216.  Samuel,  S. — Ueber  Dr.  M.  Joseph's  "  Atrophischen  Haaraus- 
fall,"  Arch.  path.  Anat.  und  Phys,,  1888,  cxiv.,  378. 

217.  Schachmann. — Contribution  au  traitement  de  la  pelade,  Ann. 
Derm,  et  Syph.,  1887,  viii.,  178. 

218.  Schutz,  J. — Beitrage  zur  Aetiologie  und  Symptomatologie  der 
Alopecia  areata,  Montshft.  f.  prkt.  Dermat.,  1887,  vi.,  97. 

219.  Schutz.  J. — Ein  Fall  von  Alopecia  neurotica,  Montshft.  f.  prkt. 
Dermat.,  1887,  vi.,  296. 

220.  Schutz,  J. — Sechs  Flille  von  Alopecia  neurotica,  Miinch,  med. 
Woch.,  1889,  xxxvi.,  124. 

221.  Stelwagon,  H.  W. — Alopecia  areata,  Internal.  Med.  Magazine, 
1892,  i.,  726. 

222.  Sympson,  E.  N. — Case  of  alopecia  of  entire  scalp.  Arch. 
Pediat.,  1892,  ix.,  840. 

223.  Thibierge,  G. — Sur  la  question  de  la  contagion  de  la  pelade, 
Ann.  Derm,  et  Syph.,  1887,  viii.,  503. 

224.  Tison,  M.  E, — Traitement  de  la  pelade  par  le  collodion  iode,  Bui. 
soc.  Med.  Prat.  Par.,  1893,  p.  255;  J.  d.  Mai.  cut.  et  Syph.,  1892.  iv., 
239. 

235.  Vaillard,  L.,  et  Vincent,  H. — Sur  une  pseudo-pelade  denature 
microbienne,  Ann.  de  I'lnstitut  Pasteur,  1890,  iv.,  446. 

236.  Variot. — Observations  et  reflexions  sur  la  pse.do-alopecie,  etc., 
Bui.  et  Mem.  Soc.  med.  d.  Hop.,  Paris,  1891,  viii.,  253;  Gaz.  med.,  1891, 
viii.,  313. 

227.  Vidal,  E.— Pelade  generalisee,  Ann.  Derm,  et  Syph.,  1889,  x., 
575. 

228.  Wermann. — (Cases)  Korrespndzbl.  d.  ilrztl.  Kreis.  u.  Bezirks- 
Vereine  Sachsens,  1891,  viii.,  1;  Mouatshft.  f.  prkt.  Dermat.,  1893,  xiv., 
29"^. 

229.  Wickham,  L. — On  a  case  of  pseudo-pelade  of  Brocq,  Brit.  Jour. 
Dermat.,  1890,  ii.,  251. 

Archambault,  P.— Jour  med.  d.  Bordeaux,  1889-90,  xix.,  424. 

Basu,  B.  J— Indian  Med.  Rec,  1892,  iii.,  8. 

Bourguet,  L.— Gaz.  hebdom.  d.  Sc.  med.  d.  Montpellier,  1887,  ix  ,  145. 

Brocq,  L.— Rev.  fj6n.  de  elin.  et  de  th6rap.,  18»9,  iii  ,  399. 

Brooke,  E.  M.  W.— Proc.  Alumnse  Assoc.  Worn.  Med.  Col.  Penn.,  1890,  xv., 

I0.i. 
Butte,  L  — Annal.  d.  la  Po  iclin.  Paris,  1892.  ii.,  361. 
Cantani,  A.— (iior.  intern,  d.  Sc.  med.,  Napoli,  1887,  ix.,  305. 
Colin,  L  —Arch  d.  Med.  et  Pharm.  mil.,  1888,  xii.,  81. 
Colquhon,  D.—Tr.  Intern.  Med  Cong.,  Melbourne,  1889,  ii.,  972. 
Coustan.— Rev.  d  Hygir^ne,  188T,  vi.,  555. 

Dubreuilh,  W.— Mem.  et  Bui.  Soc.  Med.  et  Chir.  Bordeaux,  1889,  page  288. 
Dubreuilh,  W.— Jour.  d.  Med.  d.  Bordeaux.  18H8-89,  xviii..  522. 
Giovannini.— Gior.  d.  r.  Accad.  med.  d.  Torino,  1892,  xl.,  65. 
Kazanli.  A.  I.— Vrach  St.  Petersburg,  188s,  ix.,  703. 
Krotkoff,  M.— Med.  Obozr.,  1889,  xxxii.,  391. 
Mansuroff,  N.— Klin.  Sboi'n  p.  dermat.  i  sif  ,  1889,  page  15. 
Ploquin,  A  —Annal.  de  la  Policlin.  Paris,  1890-91,  i.,  2i7. 
Pontoppidan,  E.— Hosp.  Tid.  Kopenh.,  1889.  vii.,  221. 
Robinson,  T.— Illust.  Med.  News,  188;«,  v  ,  171. 
Schindelka,  H— Oestr.  Ztschr.  f.  wissen.  Veterin,  1887,  i.,  247. 
V.  Sehlen.— Sitzungsbr.  d.  Gslschft.  f .  Morph.  u.  Phys.  in  Munchen,  1885,  i., 

117. 
Seleneff,  I.  T.— Med.  Obozr..  1890,  xxxiv.,  773. 
Tommasoli,  P.  L.— Boll.  d.  Soc   tra  i  cult.  d.  sc.  med.  in  Sienna,  1886,  iv., 

379 
Vaillard  et  Vmcent.— Arch.  Med.  et  Pharm.  mil,  1891,  xviii.,  369. 
Wermann. -Koz.  Bl.  d.  artzl.  Kreis.  in  Sachsen,  1891,  Ii.,  38. 


400  APPEXDIX. 

Atrophia  Pilorum  Propria. 
Triclwrrhexis  Nodosa. — Fragilitas.— Ringed  Hair. 

230.  Abramovitch,  A. — (Contribution  to  the  study  of  trichorrhexis 
nodosa)  Russk.  Med.,  1888,  vi.,  457;  abst.  Arch.  f.  Derm.  u.  Syph., 
1889,  xxi.,  106. 

231.  Archambault,  P. — Note  sur  un  cas  de  cheveux  moniliformes, 
Ann.  Derm,  et  Syph.,  1890.  i.,  392. 

232.  Abraham,  P.  S.— Moniliform  hair,  Brit.  Med.  Jour.,  1891,  ii., 
1148. 

233.  Abraham,  P.  S.— A  case  of  monilethrix,  Brit.  Jour.  Dermat., 
1892,  iv.,  21. 

234.  Beatty  and  Scott.— Moniliform  hairs  (monilethrix),  Brit.  Jour. 
Dermat..  1892,  iv.,  171;  Monatshft.  f.  prkt.  Dermat.,  1892.  xv..  207. 

235.  Behrend,  G. — Ueber  Trichomycosis  nodosa  (Juhel-Renoy), 
Piedra  (Osorio),  Berl.  klin.  Woch.,  1890,  xxvii.,  464. 

236.  Blaschko. — Alopecia  mit  Trichorrhexis,  Monatshft.  f.  prkt. 
Dermat.,  1891,  xiii.,  105. 

237.  GiovaDnini,  P. — Ueber  normale  Entwicklung  und  liber  einige 
Veranderunsen  der  menschiichen  Haare,  Vrtlihr.  f.  Derm.  u.  Syph., 

1887,  xiv.,  1149. 

238.  Hallopeau,  H. — Sur  un  aplasie  moniliforme  des  cheveux,  Bui. 
Soc.  Frany.  deDerm.  etSyph.,  1890,  i.,  78, 117;  Bui.  Med  ,  1891),  iv.,  501. 

239.  Hudelo.  —  Aplasie  moniliforme  familiale  des  cheveux,  Ann. 
Derm,  et  Syph.,  1892,  iii.,  1144. 

240.  Jamieson,   A. — Case  of    nodose    hairs,  Med.   Press  and  Circ, 

1888,  xlvi.,  35 

241.  Lesser. — Aplasia  pilorum  intermittens,  Monatshft.  f.  prkt. 
Dermat.,  1887.  vi.,  1099;  Archiv  f.  Dermat.  u.  Svph.,  Ib92,  Erganz- 
ungsheft  i.;  Verhandl.  d.  Deutsch.  Dermat.  Gslschft.,  1892.  p   248. 

242.  McMurrav,  W. — Notes  on  some  abnormal  conditions  of  the 
hair,  Australasian  Med.  Gaz.,  1891-92,  xi.,  279. 

243.  Montiromerv,  D.  W. — Trichorexis  nodosa,  Pacif.  M.  and  S. 
Jour.,  1887,  XXX.,  640. 

244.  Newton.  R.  C. — Nosoditas  crinium  or  trichorrhexis  nodosa,  Med. 
Rec,  1889,  xxxv.,  375. 

245.  Parker,  R.— A  novel  hair  disease  :  (?)  acne  mentagra,  Brit.  Med. 
Jour.,  1888,  ii.,  13:^5. 

246.  Pavne,  J.  F. — Hair  showing  remarkable  nodose  condition,  or 
"beaded  hairs  "  Trans.  Path.  Soc.  Lond.,  1886,  xxxvii.,  540. 

247.  Ravenel,  M.  P. — Trichorrhexis  nodosa,  Med.  News,  1892,  Ixi., 
489. 

218.  Raymond,  B. — Recherches  sur  la  trichorrexis  nodosa,  Bull.  Soc. 
FranQ.  de  Derm,  et  Syph.,  1891,  ii  ,  339;  Ann.  Derm,  et  Syph.,  1891, 
ii.,  568. 

249.  Sabouraud.  R. — Dix-sept  cas  de  cheveux  mouiliformes  (moni'e- 
thrix)  dans  une  meme  famille.  Bui.  Soc.  Fran9.  de  Derm.,  1892-93,  362; 

249a.  Sabouraud,  R.— Sur  les  cheveux  moniliformes,  Ann.  Derm,  et 
Syph.,  1892,  iii.,  781. 

250.  Steven,  J.  L. — Cases  of  trichorexis  nodosa  with  hereditary 
history,  Glasgow  ^led.  Jour.,  1889,  xxxi.,  459. 

251.  Tenneson. — Keratose  pilaire  et  aplasie  moniliforme  des  cheveux, 
Ann.  Derm,  et  Syph.,  1892,  iii.,  1146. 

Breda.  A.— Rev.  veneta  di  Si.  med.,  18S7,  vii.,  4.57. 
Sasaki.— (Trichor.  nod  )  Sei-I-Kwai  M.  Jour.,  1890,  ix.,  249. 


APPENDIX.  4:01 

Hypertrophia  Pilorum. 

252.  Aulas. — Notesurune  casd'hypertrichosede  la  main.  Loire  Med.. 
1888,  vii.,  113. 

253.  Bloom,  I.  N. — Permanent  removal  of  superfluous  hair,  Amer. 
Pract.  and  News,  1887,  iv.,  9. 

254.  Brocq,  L. — De  la  destruction  des  poils  par  I'electrolyse,  Ann. 
Derm,  et  Syph.,  1887,  viii..  460. 

255.  Brocq,  L. — De  la  destruction  des  poils  par  I'electrolyse,  Bui.  et 
Mem.  Soc.  Med.  Hop.  Paris,  1888,  v.,  147  and  387. 

256.  Brocq,  L. — Nouveaux  details  sur  la  destruction  des  poils  par 
i'electrolyse,  La  Semaine  med.,  1891.  xi.,  127. 

257.  Cliiari,  H. — Ueber  Hypertrichosis  des  Menschen,  Prag.  med. 
Wochenschr.,  1890,  xv.,  495. 

25S.  Clasen,  E. — Elektrolytische  Operationen  in  derarztlichen  Praxis, 
Deutsch.  med.  Zeitg.,  1892,  No.  63. 

259.  Dodd,  A.  H  — A  case  of  lumbar  hypertrichosis,  Lancet,  1887, 
ii.,  1063. 

260.  Dubreuilh. — De  I'epilation  par  I'electrolyse,  Jour.  d.  Med.  d. 
Bordeaux.  1890-91,  xx..5()6. 

261.  Dubreuilh. — l^pilation  electrolytique,  Bui.  Soc.  Fr.  Dermat.  et 
Syph.,  1892,  iii.,  191;  Ann.  Derm,  et  Syph.,  1892,  iii.,  495. 

263.  Faulkner. — A  peculiar  growth  of  hair  on  the  face,  N.  Y.  Med. 
Jour.,  1890,  Iii.,  155. 

263.  Gottheil,  W.  S.— Hypertrichosis,  Trans.  IX.  Int.  Med.  Cong., 
1887.  iv.,  180. 

264.  Grube,  C.  H. — Hypertrichosis,  or  unnatural  growth  of  the  hair, 
Med.  World,  1887,  v.    424. 

265.  Hardaway,  W.  A  — A  supplemental  account  of  the  case  of  a 
bearded  woman,  etc.,  Med.  News,  188s,  Iii..  490. 

266.  Hillerz.  C.— Electrolysis  in  removal  of  superfluous  hair,  Peoria 
Med   Month.,  1886-87,  vii.,  426. 

267.  Jamieson,  A. —  1  he  treatment  of  hypertrichosis.  Pract  ,  1889, 
xliii.,  1. 

268.  Joseph,  M. — Ein  Fall  von  Schwimmhosen  symmetrischen  thier- 
fellahnlichen  pilifer  pigmentosa,  Deutsch.  med.  Woch..  1888,  xv..  482. 

269.  Joseph,  M. — Ueber  Hypertrichosis  auf  pigmentirter  Haul,  Berl. 
klin.  Woch..  1892,  xxix.,  163. 

270.  Juhel-Renoy,  E.— Epilation,  Diet.  Encyl.  d.  Sc.  med.,  1887, 
XXXV.,  111. 

271.  Lawrence,  H. — Removal  of  superfluous  hair  by  electrolysis, 
Austral.  Med.  Jour.,  1891,  xiii.,  504. 

272.  Leviseur,  F.  J. — The  removal  of  superfluous  hair  by  electrolysis, 
Med.  Rec,  1893,  xli.,  209. 

273.  Leviseur,  F.  J.— Elektrolyse  in  der  Behandlung  von  Hautkrank- 
heiten,  Montshft.  f.  prkt.  Dermat.,  1890,  x.,  307. 

274.  McMurray,  W. — Notes  on  some  abnormal  conditions  of  the 
hair.  Australas.  Med.  Gaz.,  1891-92,  xi.,  279. 

275.  Miehelson,  P.— Ueber  die  galvano  chirurgischen  Depilations- 
Methoden,  Vrtljhr.  Derm.  u.  Syph..  1887,  xiv..  237. 

276.  Ohmann-Dumesnil,  A.  H.— Circumscribed  hypertrichosis  (ac- 
quired) in  the  lumbar  region,  Weekly  Med.  Rev.  (St.  Louis),  lb87, 
XV.,  317. 

277.  Ohmann-Dumesnil,  A.  II  —Circumscribed  hypertricliosis  (ac- 
quired) in  the  lumbar  region,  Jour.  Cut.  and  Gen.-Urin.  Dis.,  1888, 
vi..  97. 


dt02  APPENDIX. 

278.  Ohmann-Dumesnil,  A.  H. — Hypertrichosis  due  to  general  dis- 
ease of  the  nervous  system,  Alienist  and  Neurologist,  1887,  viii.,  483. 

279.  Ohmann-Dumesmil,  A.  H. — Hypertrichosis,  Progress,  Louisville, 
1887-88,  ii.,  403. 

280.  Oliver,  F.  W. — Electricity  in  the  removal  of  superfluous  hair, 
Med.  Reg.,  1889,  v.,  273. 

281.  Ornstein. — Fall  eines  geschwanzten  Menschen,  Berl.  Geslschft.  f. 
Anthropolog.,  March,  1885. 

282.  Ornstein. — Ueber  Sakrale  Trichosen,  Berl.  Geslschft.  f.  Anthro- 
polog., December,  1876;  December,  1877. 

283.  Overton,  J.  W. — Permanent  removal  of  superfluous  hair  by 
electrolysis,  Alabama  M.  and  S.  Age,  1888-89,  i.,  75. 

284.  Prince,  M. — Electrolysis:  proper  and  improper  methods  of  using 
it  in  the  removal  of  superfluous  hair,  Amer.  Jour.  Med.  Sci.,  1889, 
xcvii.,  479. 

285.  Regensburger,  A.  E. — Treatment  of  hypertrichosis  by  electro- 
lysis, Occident  Med.  Times.  June,  1892. 

286.  Rohe,  G.  H. — Studies  in  hirsuties,  Trans.  Int.  Med.  Cong., 
Washington,  1887,  iv.,  180. 

287.  Rohe,  G.  H. — Hypertrichosis,  Maryland  Med.  Jour.,  1887,  xvii., 
463. 

288.  Sack,  A. — Ueber  radicalepilation  auf  electrolytischem  Wege, 
Berl.  klin.  Woch.,  1892,  xxix.,  10:7. 

289.  Sommer,  W. — Ein  neuer  Fall  von  Hypertrichosis  circumscripta, 
Arch.  path.  Anat.,  1885,  cii.,  407. 

290.  Stierlin. — Spina  bifida  lumbalis  mit  Hypertrichosis,  Korre- 
spondzbl.  f.  Schweiz.  Arzte,  1^92,  xxii.,  408,  482. 

291.  Thin,  G.— Hypertrichosis,  Trans.  IX.  Int.  Med.  Cong.,  1887,  iv., 
180. 

292.  Vanderburg,  C.  R. — Treatment  of  hypertrichosis  by  electrolysis, 
Columbus  Med.  Jour.,  1887,  vi.,  245. 

293.  Woody,  S.  E. — Permanent  removal  of  hair  by  electrolysis, 
Amer.  Pract.  and  News,  1886,  ii.,  65. 

Anonymous.— Indian  Med.  Jour.,  1886,  v.,  310. 

Anonymous— Jour.  Anthrop.  Soc.  Bombay,  1386-87,  i.,  14. 

Bartels,  M.— Ztschrft.  f.  Ethnol.,  1876  18T'J,  1881,  18S3,  1884. 

Bonnet,  R.— Anat.  Hefte  Wiesb.,  1891-9-.2,  i.,  233. 

Cristiani,  A.— Arch,  di  Psichiat..  1892,  xiii.,  70. 

Ecker,  L. -Globus,  l^rs.  xiii.;  Arch.  f.  Anthrop.,  1879,  xi.;  1880,  xii. 

Ekama,  C— Album  der  Natur,  1S8S. 

Fauvelle.— Bull.  Soc.  d"Anthrop.,  1886,  ix.,  439. 

Geyl  — Biolo^.  Centrlbl.,  l88S-8.>.  viii..  >3i 

Giovannini,  S.— Gior.  d.  r.  Accad.  med.  di  Torino,  1890.  xxxviii.,  338. 

Mansuroff,  N.— Klin.  Sborn  p.  dermat.  i  sif.,  1889.  page  10. 

Meyer,  A.  B  — Vrhndlungr.  d.  Brl.  Gslshft.  f .  Anthrop.,  1886,  page  516, 

Miklucho-Maclay.— Zeitshrfr.  f  Ethnol..  1876  and  1881. 

Neisser.— Jahrb.  d.  Schles.  Gslshft.  f.  vatrl.  Kult..  1885,  Ixii.,  66. 

Ornstein.  B.-Zeitschrft.  f.  Ethnol.,  1875,  1876,  1877, 1679,  1880,  and  1S84; 

Archiv  f.  Anthropol.,  18P6. 
Parreydt,  J.— Deutsche  Montshft.  f.  Zahnheil,  1886.  iv.,  2. 
Ranke.— Vrhndlng.  d.  Munch.  Anthrop.  Gslshft.,  188S,  i.,  4. 
Tepljascbin,  A  —Med.  Obozr.,  l*^sS,  xxix  .  39. 
Virchow,  R.— Zeitschrft.  f.  Ethnologie,  1875,  vii.;  1884,  xvi. 
Zojo,  G.— Boll.  Scient.  Pavia,  1886,  xiii.,  33. 

Sycosis. 

294.  Bockhardt,  M. — Ueber  die  Aetiologie  und  Therapie  der  Impeti- 
go und  der  Sycosis,  Monatshft.  f.  prk.  Dermat.,  1887,  vi.,  450. 

295.  Brooke,  H.  G. — The  contagious  nature  of  sycosis,  Brit.  JouTt 
Dermat.,  1888-9,  i.,  467.    . 


APPENDIX.  403 

296.  Davidson,  A.  R. — Sycosis  non-parasitica,  Buf.  Med.  and  Surg. 
Jour.,  1886-7,  xxvii.,  215. 

297.  Dubreuilh,  W. — Deux  cas  de  sycosis  non  parasitaire,  Annal.  de 
1.  Polyclin.  Bord.,  1889,  i.,  113. 

298.  Fabry,  J. — Zur  Aetiologie  der  Sycosis  simplex,  Deutsch.  med. 
"Woch.,  1891,  xvii.,  976. 

299.  Hardaway,  W.  A.— Inflammation  of  the  hair  follicles  within  the 
nares,  Jour.  Cutan,  and  Ven.  Dis.,  1886,  iv.,  360. 

300.  Hutchinson,  J. — Case  of  severe  sycosis  of  pubes,  Archv.  Surg., 
1889-90,  i.,  264. 

301.  Hutchinson,  J.— Sycosis  ;  acne  of  scalp  with  lichenous  and  pus- 
tular acne  of  trunk,  Archv.  Surg.,  1889-90,  i.,  371. 

302.  Jackson,  G.  T. — Sycosis :  a  clinical  study,  Jour.  Cutan.  and 
Gen.-Urin.  Dis.,  1889,  vii.,  13. 

303.  Knott,  J.— Tinea  sycosis.  Lancet,  1890,  i.,  294. 

304.  Kromayer,  E. — Beitrag  zur  Therapie  der  Sycosis,  Therap.  Mo- 
natshft.,  1892,  vi.,  181. 

305.  IVIichelson,  P. — Ueber  Trichofolliculitis  bacterica,  Deutsch.  med. 
Woch.,  1889,  XV.,  586. 

306.  Ohmann-Dumesnil. — Treatment  of  sycosis,  St.  Louis  M.  and  S. 
Jour.,  1890,  Iviii.,  137. 

307.  Rona,  S.— -(Parasitic  sycosis  in  Hungary)  Pest.  med.  chir.  Presse, 
1887  ;  (abst.)  Jour.  Cutan.  and  Gen.-Urin.  Dis.,  1887,  v.,  351. 

308.  Rosenthal,  O. — Beitrag  zur  Aetiologie  und  zur  Behandlung  der 
Sycosis  vulgaris,  Deutsch.  med.  Woch.,  1889,  xv.,  459. 

309.  Shoemaker,  J.  V. — Pathology  and  treatment  of  sycosis,  Jour. 
Am.  Med.  Assoc,  1890,  xv.,  177. 

310.  Salomon,  L.  F.— Sycosis,  New  Orleans  M.  and  S.  Jour.,  1887-8, 
XV.,  12. 

311.  Tommasoli,  B. — Ueber  bacillogene  Sykosis,  Monatshft.  f.  prkt. 
Dermat.,  1889,  viii.,  483. 

312.  Unna,  P.  G. — Hyphogenic,  coccogenic  und  bacillogcnic  Sycosis, 
St.  Louis  M.  and  S.  Jour.,  1889,  Ivii.,  81. 

313.  Unna,  P.  G.  -  Ueber  Ulerythema  sykosiforme,  Monatshft.  f .  prkt. 
Derrnt.,  1889,  ix.,  134. 

314.  Williams,  W. — A  localized  epidemic  of  acne  sycosis  traceable  to 
a  barber's  shop.  Lancet,  1890,  i.,  346. 

315.  Zeisler,  J. — Epilation  ;  its  range  of  usefulness  as  a  dermato- 
therapeutic  measure.  Jour.  Cut  and  Gen.-Urin.  Dis.,  1891,  ix.,  444; 
Trans.  Amer.  Derm.  Assoc,  1891. 

Martin,  H.— Arztl.  Veroinsbl.  f .  Peutschl.,  1890,  xvii.,  488. 

Nystrooi,  A.— Hy^ei..  Stocktiolm,  l!S90. 

Rona,  S.— Orvosi  hetil.,  1887,  xxxi  ,  385. 

Rona,  S.— Pest.  med.  chir.  Presse.  1887,  xxiii.,  353. 

Rosenberg,  M.— Arztl.  Mitth.  a  Baden,  1891,  xiv.,  109. 

TRicnoPHYTOSis  Capitis. 

316.  Allyn,  H,  B  — Treatment  of  ringworm  of  the  scalp,  Med.  and 
Surg.  Reprtr.,  1887,  Ivii.,  106. 

317.  Audrain,  J.— Contribution  a  I'etude  de  la  trichophytie  tonsu- 
rante,  Ann.  Derm,  et  Syph.,  1892,  iii.,  1051. 

318.  Brocq,  L. — Traitement  local  de  la  trichophytie  du  cuir  chevelu 
(teigne  tondante),  Ann   Derm,  et  Syph.,  1890,  i  ,  147. 

319.  Busquet,  G.  P. — Du  traitement  antiseptique  des  teignes,  etc., 
Ann.  Derm,  et  Syph.,  1892,  iii.,  269. 

330.  Butte,  L. — De  I'emploi  du  collodion  iode  dans  le  traitement  des 


tt04:  APPENDIX. 

teignes  pour  remplacer  I'epilation,  Jour,  d.  Mai.  cutan.  et  syph.,  1892, 
iv.,  459. 

321.  Cantrell,  J.  A. — Some  experiments  with  electrolysis  in  cases  of 
tinea  tonsurans,  Polyclinic,  Phil.,  1888-9,  vi.,  141. 

321a.  Charon  et  Gevaert,  Jour,  de  Med.  de  Brux..  1887,  page  673. 

322.  Dockrell,  M. — Hydronapthol  as  specific  in  the  treatment  of  tinea 
tonsurans,  Lancet,  1889,"  ii.,  110, 

323.  Dubreuilh,  W. — De  quelques  formes  rares  de  la  trichophytie  du 
cuir  chevelu.  Jour.  Mai.  cut.  et  syph.,  1891,  iii..  438. 

324.  Dubrisay. — L'ecole  des  tei'gneux  a  IHopital  St.  Louis,  Rev.  de 
B.yg.  Par.,  1887,  ix.,  296. 

325.  Duhring,  L.  A. — Experiences  in  the  treatment  of  chronic  ring- 
•worm  in  an  institution,  Am.  J.  Med.  Sc,  1892,  ciii.,  109. 

326.  Eddowes,  A. — The  treatment  of  ringworm  of  the  scalp,  Brit, 
3Ied.  Jour.,  1893,  i.,  785. 

327.  Eloy,  C. — Un  traitement  nouveau  de  la  teigne  tondante,  Gaz. 
hebdom.  de  3Ied.,  1889,  xxvi.,  475. 

328.  Fournier,  H, — Les  hopitaux  et  les  ecoles  de  t«igneux,  J.  Mai. 
derm,  et  syph.,  1891,  iii.,  643. 

329.  Furthmann,  W,,  und  Neebe,  C.  II.— Vier  Trichophytonarten, 
Monatshft.  f.  prkt.  Dermat.,  1891,  xiii.,  477. 

330.  Harrison,  A.  J. — Further  researches  on  the  treatment  of  tinea 
tonsurans,  Brit.  M.  Jour.,  1889,  i.,  465. 

331.  Hutchison.  J  — Tincture  Siegesbeckia  orientalis  in  ringworm, 
Brit.  M.  Jour.,  1887,  i.,  1384. 

332.  Hutchinson,  J. — Notes  on  cure  of  ringworm.  Arch.  Surg.,  1889 
-90,  i.,  276. 

333.  Hutchinson,  J. — Herpes  tonsurans  which  travelled  from  scalp  to 
hand.  Arch.  Surg.,  1889-90,  i.,  367. 

334.  Juhel-Renoy.  E. — Teignes  :  nature  et  traitement,  Arch.  gen.  de 
Med.,  1887,  ii.,  84. 

335.  Kerley,  C.  G. — A  report  of  thirty-one  cases  of  ringworm  of  the 
scalp  treated  successfully  with  bichloride,  kerosene,  and  iodine,  N.  Y. 
Med.  Jour.,  1891,  liy.,  396. 

336.  Leyiseur,  F.  J. — Irritation  and  the  treatment  of  ringworm  of  the 
scalp,  Med.  Rec,  18-9,  xxxv.,  594. 

387.  Leyiseur.  F.  J. — The  prophylaxis  of  ringworm  of  the  scalp, 
Post-Grad.,  1889-90,  v.,  36  ;  N.  Y.  .Med.  Jour.,  18S9,  1.,  43. 

338.  Marianclli.  A.— Sulla  cura  della  tigna  tonsurante  del  capillizio, 
Giorn.  ital.  d.  Mai.  yen.,  1890,  xxv.,  359. 

339.  Mazza,  G  — Di  una  forma  rara  di  tricophitiasis.  Giorn.  ital.  d. 
Mai.  ven.,  1889,  xxiv..  168. 

310.  Megnin,  P. — Difference  specifique  entre  le  champignon  de  la 
teigne  des  poules  et  celui  de  favus,  Compt.  rend.  Soc.  biol.,1890,  ii.,  151. 

341.  Morris,  M. — Ringworm  in  the  elementary  schools.  Lancet.  1891, 
ii.,  348. 

342.  Newman,  W. — Short  notes  on  ringworm  transmission  from 
cows,  Brit.  Med.  Jour..  1889,  ii.,  1276. 

343.  Noyes,  A.  W.  F  —The  artificial  cultiyation  of  trichophyton  fun- 
gus (ringworm)  of  the  skin  and  hair,  Australian  Med.  Jour.,  Ib91,  xiii., 
473. 

344.  Obemdorfer,  J.— Die  differential  Diagnose  und  Therapie  der 
Tinea  trichophytina,  N.  Y.  med.  Presse,  1S86-7,  iii.,  143 

345.  Ohmann-Dumesnil,  A.  II. — Case  of  ringworm  of  the  scalp 
complicated  by  pustular  eczema,  Cincin.  Med.  News,  1890,  xix..  376; 
Brit.  J.  Dermat.,  1888-9,  i.,  264. 


APPENDIX.  405 

346.  Pelizzari. — Trichophyton  tonsurans,  abst.  Monatshft.  f  prkt. 
Dermat.,  1887,  vi.,  1049. 

347.  Purdon,  H.  S. — Note  on  the  treatment  of  tinea  tonsurans.  Dub. 
J.  M.  Sc,  1889,  Ixxxviii  ,  299. 

348.  Qaincke,H. — Ueber  Herpes  tonsurans,  Monatshft.  f.  prkt  Derm., 
1887,  vi,  987. 

349.  Quinquaud. — Les  teignes  ■  la  teigne  faveuse,  la  trichophytie,  la 
pelade,  Gaz.  hop.,  1890,  Ixiii..  990. 

350.  Quinquaud. — Prophylaxie  et  traitement  de  la  trichophytie. 
Union  med.,  1890,  1.,  49. 

351.  Quinquaud  et  Butte. — Note  sur  les  resultats  obtenus  dans  le 
traitement  de  la  trichophytie,  Bui.  Soc.  Fran9.  d.  Dermat    1891.  ii  ,  152. 

352.  Reynolds,  H.  J. — X  new  method  of  treating  the  vegetable  parasi- 
tic diseases  of  the  skin,  Trans.  Inter.  Med.  Cong.,  18':i7,  iv..  189. 

353.  Roberts,  H.  L. — Observations  on  the  artificial  cultivation  of  the 
ringworm  fungus,  Brit.  J.  Dermat  ,  1888-9.  i.,  359. 

354.  Sabouraud,  R. — Contribution  t  Tutude  de  la  trichophytie  hu- 
maine,  Ann.  Derm,  et  Syph.,  1892,  iii.,  1061  et  seq. 

355.  Sabouraud,  R. — Nouvelles  recherches  sur  lamycologie  du  tricho- 
phyton ;  des  especes  de  trichophyton  a  gros.ses  spores,  Bui  de  la  Soc. 
Fran9.  de  Dermat.  et  Syph  ,  1893.  iv.,  59. 

356.  Smith,  A. — Ringworm  of  the  head  and  its  treatment.  Lancet, 
1886.  i.,  418. 

357.  Tenneson  et  Berdal. — Trichophytie  disseminee  des  regions 
glabres  et  du  cuir  chevelu  a  ITige  adulte,  Bui  Soc.  Fran 9.  Derm,  et 
Syph.,  1882,  iii.,  314  ;  Ann.  Derm,  et  Syph..  1892.  iii  .  709. 

358.  Thin,  G. — Pathology  and  treatment  of  ringworm,  Practitioner, 
18S7,  xxxviii.,  241. 

359.  Thin,  G. — Experimental  researches  concerning  trichophytina 
tonsurans,  Brit.  M.  Jour.,  1889,  i.,  397. 

360.  Thin,  G. — Pathology  and  treatment  of  ringworm.  Wood's  M. 
and  S.  Monog.,  1889,  iv.,  721. 

361.  Trichophytosis.— Cong.  Internat.  de  Derm,  et  Syph.,  1890,  p.  191. 

Arnaud,  F.— Marseilles  mM.,  1688,  xxv.,  534. 

Bertarelli,  A.— Boll,  di  Poliambul.  di  Milan,  1890,  iii.,  1. 

Bertrand,  L.  E.— Arch.  d.  m6d.  Nav.,  1891,  Iv.,  471. 

Butte,  L.— Assistance,  Par.,  1891,  i  ,  204. 

Cramoisy.— Compt.  rend.  Cong,  inter,  d.  homoeop.,  1889,  p.  199. 

D6claux,  E.— Compt.  rend.  Soc.  de  Biol.,  Paris. 

Laennec,  T.-Gaz.  m^d.  d.  Nantes,  l891-'2,  x.,  53. 

Mazza,  G.— Boll.  d.  r.  Accad.  med.  d.  Genoa.  1891,  vi..  1. 

M6gnin,  P.— Bull.  soc.  centr.  d.  M»'d.  vet  .  1890,  viii.,  183. 

Monteverdi,  L— Bol.  d.  Comit.  med.  Cremona,  188"),  v.,  209. 

Peroni,  G.— Giorn.  d.  r.  Accad.  med.  d.  Torino,  1891,  xxxix.,  33. 

Simon,  R.  M.-Illust.  Med.  News.  1890.  vi.,  100. 

Simon,  R.  M.— Rev.  med.  de  TEst,  1890.  xxii.,  493. 

Taussig.— Bol.  d.  r.  Accad.  med.  d.  Roma,  1890,  xvii.,  54. 

Trabut.— Alger,  med.,  1888,  xvi.,  220. 

TRicnopnYTOSis  Barb^. 

362.  Besnier,  E. — Traitement  du  sycosis  (parasitaire).  Jour.  d.  Med. 
etChir.,  1887,  Iviii.,  248. 

363.  Besnier,  E.— Trichophytie  erythemateuse  circinee,  etc.,  Ann. 
Derm,  et  Syph..  18^9,  x.,  111. 

364.  Feye.— Epidemic  de  trichophytie,  Arch.  med.  Beiges,  1886, 
XXX.,  17. 

365.  Gottheil,  W.  S.— Barber's  itch,  Med.  News,  1892,  Ixi.,  342. 

366.  Hallopeau.— Trichophytie  de  la  barbe,  Ann.  Derm,  et  Syph., 
1889,  X.,  327, 


406  APPENDIX. 

367.  Hutchinson,  J. — Case  of  ringworm  of  the  beard,  Arch.  Surg., 
18«9,  i.,  55. 

Favus. 

368.  Boer,  O. — Zur  Biologie  des  Favus,  Yrtljhr.  f.  Derm.  u.  Syph., 
1887,  xiv.,  429. 

369.  Busquet,  G.  P, — Du  traitement  antiseptique  des  teignes  et  en 
particulier  de  la  pelade,  Ann.  Derm,  et  Syph  ,  1892,  ill.,  269. 

370.  Busquet,  G.  P. — De  rorigine  muridienne  du  favus,  Ann.  Derm. 
etSyph..  1892,  iii.,  916. 

371.  Elseubers:,  A. — Ueber  den  Favuspilz,  Arch.  Derm.  u.  Syph., 
1889,  xxi.,  179,  and  1890,  xxii  ,  71  ;  Gaz  lek.  Warsz.,  1889,  ix.,  170, 
and  1890,  x,,  208. 

372.  Esteves,  J. — Tratamiento  del  favus  por  la  resorcina,  Annal.  d.  1. 
Assistancia  publica,  Buenos  Ayres,  1891 ;  abst.  Ann.  Derm,  et  Syph., 
1891,  ii.,  798. 

373.  Evans,  S.  G. — Favus  and  its  treatment  ;  results  in  129  cases, 
Med.  Rec,  1892,  xli..  490. 

374.  Fabry,  J. — Klinisches  und  Aetiologisches  ueber  Favus,  Arch. 
Derm.  u.  Syph.,  1889,  xxi.,  461. 

375.  Feulard.  H. — La  favus  et  la  pelade  en  France,  Ann.  Derm,  et 
Syph.,  1892,  iii.,  1118. 

376.  Frank  L  F  —Favus,  Monatshft.  f.  prkt.  Dermat.,  1891,  xii., 
254. 

377.  Hutchinson,  J. — A  very  severe  case  of  favus.  Arch.  Surg.,  1890, 
i.,  9. 

378.  Jadassohn,  J. — Demonstration  von  Favusculturen,  Vrhndl.  d. 
deutsch.  dermat.  Gslschft..  1889,  i.,  77. 

379.  Jadas.sohn.  J. — Bemerkung  zu  der  Arbeit  Elsenberg's  "  Ueber 
den  Favuspilz  bei  Favus  herpeticus,"  Arch,  Derm.  u.  Syph.,  1890, 
xxii.,  451. 

380.  Jamieson,  W.  A. — Favus  occurring  under  somewhat  peculiar 
circumstances  as  to  origin.  Brit.  Jour.  Dermat.,  1893,  v.,  140. 

381.  Kaposi,  M. — Zur  Patliologie  und  Therapie  des  Favus,  Intrnt. 
klin.  Rundschau,  1891,  v..  503. 

382.  Krai,  F.— Ueber  den  Favuserreger,  Wien,  med.  Woch.,  1890,  xl., 
1441  ;  Trans.  X.  Int.  Med.  Cong.,  1891,  iv.,  13. 

383.  Krai,  F. — Untersuchungen  iiber  Favus,  Beitrage  z.  Derm.  u. 
Syph.,  1891,  i.  79 

384.  Mibelli,  V. — Di  alcuni  casi  di  tigna  favosa  curata  con  Toleato  di 
rame  senza  depilazione,  Bol.  d.  cult.  d.  Sc.  med.,  1888. 

385.  Mibelli,  V. — Di  alcuni  casi  di  tigna  favosa  curata  con  I'oleato  di 
rame  senza  depilazione,  Giorn.  ital.  Mai.  ven.,  1888,  xxiii.,  329. 

386.  Mibelli,  V.— Sul  fungo  del  favo,  Riforma  medica,  1891,  p.  817, 
and  1892;  Ann.  Derm,  et  Syph.,  1892,  iii.,  228. 

387.  Morris,  M. — An  extensive  case  of  favus,  Brit.  Jour.  Dermat., 
1891,  iii  ,  101. 

388.  Munnich,  A.  J. — Beitrag  zur  Kenntniss  des  Favuspilzes,  Arch.  f. 
Hygiene,  1888,  viii.,  246. 

389.  Neumann,  S. — Identite  du  favus  des  poules  et  du  favus  de 
I'homme,  Compt.  rend.  Soc.  biol.  Par..  1886,  iii  ,  173. 

390.  Peroni,  G. — Di  un  nuovo  metodo  pratico  per  curare  la  tigna  fa- 
vosa, Gior.  d.  r.  Accad.  d.  Med.  Torino,  11591  ;  abst.  Ann.  Derm,  et 
Syph.,  1891,  ii.,  797. 

391.  Pick,  F,  J. — Experimenteller  Beitrag  zur  Kenntniss  des  Favuser- 
regers,  Wien.  klin.  Woch.,  1890,  iii.,  (542. 


APPENDIX.  407 

392.  Pick,  F.  J.— Untersuchungen  uber  Favus,  Zeitschr,    f.   Heilk., 

1891,  xii.,  153  ;  also  Arch.  Derm.  u.  Syph.  Ergnzhft.,  1891;  also  Beitrag 
z.  Dermat.  u.  Sypb.,  1891,  i.,  57. 

393.  Plaut,  H.  L.— Beitriige  zur  Favusfrage,  Cntrlbl.  f.  Bakteriol.  u. 
Parasitk.,  1892,  xi.,  357. 

394.  Quincke,  H. — Ueber  Favuspilze,  Arch  v.  expermnt.  Palh.  u. 
Pharm.,  1886-7,  xxii.,  62  ;  also  Vrhndl.  d.  Cong.  f.  Int.  Med.,  1886,  v., 
467  ;  also  Mntshft.  f.  prkt.  Dermat.,  1887,  vi.,  981. 

395.  Quincke,  H. — Doppelinfektion  niit  Favus  vulgaris  und  Favus 
herpeticus.  Mntshft.  f,  prkt.  Dermat.,  1889,  viii.,  49. 

396.  Quinquaud. — Les  teignes  :  la  teigne  faveuse,  la  trichophytie,  la 
pelade,  Gaz.  hop.,  1880,  Ixiii.,  990. 

397.  Reynolds,  H.  J.— Favus,  Med.  Age,  1889,  vii.,  270. 

398.  Itossi,  A. — La  tigna  favosa  della  facia,  La  Kiforma  medica,  1891, 
p.  87. 

399.  Schuster. — Ueber  Favusbehandlung,  Mntshft.  f.  prkt.  Dermat., 
1889,  ix.,  1. 

400.  Schwengers. — Ueber  Einwirkung  von  Medikamentenauf  Kultu- 
ren  von  Favus  und  Trichophyton,  Mntshft.  f.  prkt.  Dermat.,  1890,  xi., 
155. 

401.  Unna,  P.   G. — Drei  Favusarten,  Montshft.   f.   prkt.   Dermat., 

1892,  xiv.,  1  ;  Brit.  Jour.  Derm.,  1892,  iv.,  139. 

402.  Unna,  P.  G. — Die  bisher  bekanuten  neun  Favusarten,  Montshft. 
f.  prkt.  Dermat.,  1893,  xvi.,  17. 

Ambrosi,  A.— Raccoglitore  med.  Forli.,  1888,  vi.,  282. 

Andronico,  C— Bol.  d.  Sc.  med.  d.  Bologna.  1886,  xvii.,  377. 

Dahl,  J.— Norsk.  Mag  f  Laegevidensk.,  1888,  iii..  392. 

Desville,  L.-Jour.  d.  Sc  med.  d.  Lille,  1892.  ii.,  49. 

Desmet,  E.— La  Clinique,  Brux.,  1889,  iii.,  341. 

Hiorth,  W.— Norsk.  Mag.  f .  Laegeviden.sk.,  1888,  iii.,  105. 

Kovalevski,  I.— Archv.  vet.  i  auk.  St.  Peters.,  1887,  xvii.,  47. 

Krasin,  A  A.— Vrach.,  18iK),  xi.,  5i07. 

Mibelli,  V  — Riforma  med.,  1891,  vii..  817. 

Eossi,  A.— Riforma  med.,  1891,  vii.,  87. 

V.  Walsen,  A.  J.— Nederl.  mil.  geneesk.  Arch.,  1889,  xiii.,  333. 

Pediculosis. 

403.  Besnier. — Destruction  des  pediculi  pubis.  Jour,  de  Med.  et  de 
Chirurg.,  1887,  Iviii.,  248. 

404.  Cantrell,  J.  A.— Pediculosis  capillitii,  Ann.  Gynec.  and  Pediat., 
1889-90,  iii.,  485. 

405.  Frazer,  W. — Pediculi :  their  treatment  by  parasiticides,  Med. 
Press  and  Circ,  1885,  ii.,  550 

406.  Goldenberg,  H.— Ueber  Pediculosis,  Berl.  klin.  Woch.,  1887, 
xxiv.,  866. 

407.  Greenough,  F.  B.— Clinical  notes  on  pediculosis,  Boston  M.  and 
S.  Jour.,  1887,  cxvii.,  469. 

408.  Grellety.— Traitement  de  la  phthiriase,  Jour,  de  Mai.  cut.  et 
syph.,  1890-91,  ii.,  20. 

409.  Reiser,  I.— Pediculi  pubis  auf  der  behaarten  Kopfhaut,  Arch. 
Derm.  u.  Syph.,  1892,  xxiv.,  589. 

410.  Jamieson,  W.  A.— On  some  of  the  rarer  effects  of  pediculosis, 
Brit.  J.  Derm.,  1888-9,  i.,  321. 

411.  Mathews,  P.  W.  P.— Notes  on  phthiriasis,  Canad.  M.  and  S. 
Jour.,  1886-7,  xv.,  45. 

412.  Payne,  J.  F.— Maculae  ccerulca)  and  other  symptoms  produced 


1:08  APPENDIX. 

Dy  pediculosis  pubis,  Brit.  J.  Derm.,  1890,  ii.,  209;  also  Mntshft.  f.  prkt 
Derm.,  1890,  xi.,  388. 

413.  De  Schweinitz  and  Randall. — Phtlieiriasis  palpebrarum,  Univ. 
SL  Mag.,  1891-2,  iv.,  137. 

41-4.  Trouessart. — Sur  une  phthiriase  du  cuir  chevelu  causee  par  la 
phtliirius  inguinalis,  Compt.  rend.  Acad.  Sc,  Par.,  1891,  cxiii.,  1067. 

Grellety.— Actuality  mM.,  1890,  ii..  161. 
Pjatnitski.— Med.  Obozr.  Mosk.,  1886,  xxvi.,  288. 

Parasitic  Diseases. 

415.  Behrend,  G. — Ueber  Trichomycosis  nodosa,  Berl.  klin.  Woch., 
1890,  xxvii.,  464. 

416.  Juhel-Renoy,  E.— Recherclies  histo-biologiques  et  histologiques 
5ur  la  trichomycosis  nodulaire,  Ann.  Derm,  et  Syph.,  1890,  i.,  765. 

417.  Juhel-Henoy,  E. — Note  pour  servir  de  I'histoire  de  la  piedra, 
Compt.  rend.  Soc.  biolog.  Paris,  1888,  v.,  827. 

418.  Patieson,  R,  G. — Trichomycosis  nodosa,  a  bacillary  disease  of 
the  hair,  Brit.  M.  Jour.,  1889,  i.,  1166  ;  also  Tr.  Roy.  Acad.  Med.  Ir., 
1889,  vii.,  85. 

419.  Patteson,  R.  G. — Trichomycosis  nodosa,  a  note  on  its  character, 
etc.,  Dub.  J.  M.  Sc,  1889,  Ixxxviii.,  207 ;  Brit.  J.  Derm.,  1890,  ii.,  101. 

Oudemans  and  Pekelharing.— Arch.  neerL  d.  Sc.  exact.,  1886,  xx.,  401 

Daxdruff. 

420.  Gamberini. — Pitiriasi  del  capo,  Giorn.  ital.  d.  Mai.  ven.,  1891  ; 
Archv.  f.  Derm.  u.  Syph.,  1893,  xxv.,  307. 

420a.  JacksoD,  G.  T.— Seborrha?a,  Gaillard's  Med.  Monthl.,  1890. 

421.  Mannino,  L. — II  microsporon  dispar  di  Yidal  nella  seborrea, 
Giorn.  ital,  d.  Mai.  ven.,  1886,  xxi,,  84. 

422.  Unua,  P.  G. — Was  wissen  wir  von  der  Seborrhcea,  3Intshft.  f. 
prkt.  Derm.,  1897,  vi.,  698. 

423.  Van  Harlingen,  A. — The  pathology  of  seborrhcea,  Arch.  Derm., 
1878,  iv.,  97. 

Keratosis  Pilaris. 

424.  Brocq,  L. — Notes  pour  servir  u  I'histoire  de  la  keratose  pilaire, 
Ann.  Derm,  et  Syph.,  1890,  i.,  25. 

425.  Hutchinson,  J. — Cacotrophia  folliculorum,  Annal.  Surg.,  1892-3, 
iv.,  45. 

Plica  Polonica. 

426.  De  Amicis. — Du  trichoma  vrai,  Ann.  Derm,  et  Syph.,  1892,  iii., 
1182. 

427.  Jarochevski,  S.  — Un  cas  de  tricoma  (plique  polonaise)  aigu, 
abst.  Jour.  Mai.  cutan.,  1892,  iv.,  533 

N^VUS  PiLOSUS. 

428.  Chiari,  H. — Ueber  Hypertrichosis  beim  Menschen,  Prag.  med. 
AVochsch.,  1890,  xv.,  495. 

Ornstein.— Vrhndlng.  der  Gesellschft.  f.  Anthrop.,  Ethnol.,  etc.,  1884. 


IKDEX. 


PAGE 

Abscess 242 

Acbor 314 

barbatus 329 

Achorion  Schonleinii 260 

Acne. 190,332 

decalvante 198 

indurata .251 

keloidique 344 

mentagra.., 182 

pilaire  cicatricielle   depi- 

lante 198 

sycosis. 182 

Adenotrichie 182 

Alopecia 80,221,269 

Alopecia  adnata 81 

symptoms 81 

etiology 81 

pathology 81 

prognosis 82 

treatment 82 

Alopecia  areata 115,  220 

symptoms 116 

etiology 118 

pathology 124 

diagnosis 120 

prognosis 131 

treatment. .  138 

Alopecia  circumscripta 115 

follicularis 96 

f  urf  uracea 92 

occidentalis 115 

pityrodes. .  „ 92 

Alopecia  prematura  idiopathica,  85 

symptoms , 85 

etiology 85 

pathology 88 

prognosis 89 

treatment.. , 90 

Alopecia  prematura  symptoma- 
tica  91,  129 

symptoms 91 

etiology 96 

pathology 99 

prognosis 100 


PAGE 

Alopecia  premature  symptoma- 
tica—diagnosis 101 

treatment 101 

Alopecia  senilis 83,  129 

symptoms tZ 

etiology 83 

pathology 84 

prognosis 84 

treatment 84 

Alopecia  syphilitica 94,  130 

Alopecie    cicatricielle    innomi- 

nee 198,  199 

Aplasia  pilorum  intermittens.  .153 

Aplasia  pilorum  propria 153 

symptoms 154 

etiology 154 

pathology 155 

treatment 156 

Area  Celsi 115 

occidentalis  diffluens 115 

occidentalis  serpens 115 

occidentalis  tyria 115 

Arrectores  pilorum 31 

Athrix  depilis 80 

Atrichia 80 

Atrophia  pilorum  propria 140 

Bacterium  decalvans 126 

Baldness 80 

circumscribed 115 

congenital 81 

premature 85 

senile 84 

Barber's  itch 182,  245,  329 

Bartfinne -. 182 

parasitische 245 

Bartflechte 182 

Bearded  women 164 

Bed-hair 39 

Beigel's  disease 290 

Bibliography 365 

appendix 391 

Black  hair 78 

Blepharitis  ciliaris 334 


410 


INDEX. 


PAGE 

Blood-vessels 30 

Blue  hair 78 

Brown  hair 78 

Brushes,  selection  of 54 

Brushing =  54 

Cacotrophia  folliculorum 103 

Calotte , 271 

Calvezza  80 

Calvities 80 

Canities  63 

symptoms .  63 

etiology 68 

pathology 68 

treatment 71 

Canities,  acquired  63 

congenital  63 

sudden   ...  , 66 

Cheveux  monilif ormes ........  153 

Clastothrix 144 

Coccogenous  sycosis  182 

Color  altered  by  chemicals 79 

change  after  death 78 

Combing 55 

Combs,  selection  of 55 

Cortex,  the  23 

Crustalactea 314 

Cuticle,  the 24 

Cutis  anserina 311 

Dandruff,  symptoms 299 

e'tiology 301 

pathology 302 

diagnosis 303 

treatment     304 

Dartre  furfuracee  arrondie. . .  .205 
pustuleuse  mentagra. .  .182 

Dasyma 158 

Defluvium  capillorum 95 

Depilatio 80 

Depilatories 176 

Dermatitis 322 

Dermatitis     papillaris    capilli- 

tii 198,344 

symptoms 344 

etiology 348 

pathology 348 

diagnosis  348 

prognosis  349 

treatment.    349 

Dermatitis  papillomatosa  capil- 

litii 344 

Dermatomykosis barbae  nodosa, 245 

favosa 256 

palmellina....295 


PAGK 

Dermatomykosis  tonsurans 205 

trichophytina,205 

Distichiasis 181 

Duhring's  parasitic  disease 296 

Dyes  for  hair 72 

Ecthyma 359 

Eczema.  189,  219,267,  303,  312,  359 

Eczema  barb* 250,  329 

symptoms 329 

etiology 330 

diagnosis 331 

prognosis 332 

treatment  332 

Eczema  capitis 314 

symptoms 314 

etiology 317 

diagnosis 320 

treatment 323 

prognosis. 329 

Eczema  narium  337 

Eczema  palpebrarum 334 

symptoms 334 

etiology 335 

treatment 335 

Eczema  seborrhoicum . . .  299,  301 

Electrolysis 170 

Embryonal  hair  change 34 

End  atrophy 156 

Epithelioma 251,332,360 

Erbsrrind 256 

Erysipelas 321 

Erythema  ichorosum 314 

Favus .129,  218,  256,  323 

symptoms 256 

etiology  260 

pathology 261 

diagnosis ...266 

prognosis 270 

treatment 270 

Fikosis 182 

Flechte,  scherende 205 

Fluxus  pilorum 80 

Foetal  hair 32 

Folliculite  epilante 198,  199 

Folliculitis  barbae 182 

Folliculitis  decal vans 1 97 

symptoms 197 

etiology 200 

pathology 200 

diagnosis 200 

treatment  200 

prognosis 200 


INDEX. 


411 


PAGE 

Folliculitis  pilorum 182 

Fragilitas  crinium    symptoma- 
tica  140 

etiology ....141 

treatment 141 

Fragilitas  crinium  idiopathica.141 

patliology 142 

etiology 143 

treatment 143 

Framboesia 344 

Fuchsraude 80 

Gangrsena  alopecia 80 

Gourme 314 

Granuloma  tricliophyticum  . .  .238 

Gray ness 63 

Green  hair 76 

Hair,  anatomy  of 21 

appearances  of 41 

bed 39 

centres 36 

change  at  puberty 35 

chemical  constitution  ...  48 

color  of 43 

curly o 47 

cutting 57 

development  of 82 

diameter  of /. .  46 

discoloration  of I.   74 

dressing .56 

dyes  72 

elasticity  of 48 

electricity  of 48 

embryonal  change  in. . .  .   34 

follicle     26 

general  description  of . . .  21 

growth  of 35,  45,  46 

hygiene  of 51 

length  of 45,  46 

muscles  of. 50 

number  of 46 

papilla 29 

physiology  of 33 

pigment 24 

racial  dillerences 47 

regeneration  of 40 

root 24 

shedding  of 38 

superfluous 158 

technique 43 

transplantation  of 46 

uses  of 49 

Hair-cone,  primitive 33 


PAGE 

Hairiness 158 

Hats 57 

Henle's  layer 28 

Heroes  circinatus 205 

circine  parasitaire  . . .  .205 
pustulosus  mentagra.  .182 

sqiiamosus  205 

tonsurans 205 

tonsurans  barbaj 245 

tonsurante 205 

Hirsuties 158 

Huxley's  layer 28 

Hyperkeratosis  pilaris .310 

Hypertrichosis 158 

symptoms 158 

etiology 166 

treatment 169 

Hypertrichosis  acquisita     par- 
tialis  163 

congenita     par- 
tialis   162 

congenita     uni- 
versalis   158 

pilorum 158 

transitory.    ...  165 

Ichthyosis 312 

Impetigo 322 

figurata 314 

lactantia 314 

muciflua 314 

mucosa  314 

sycosiforme 329 

Kahlheit... 80 

kreisflcckige 115 

Keratosis  pilaris 310 

symptoms .310 

etiology 311 

pathology 311 

diagnosis 311 

treatment 312 

prognosis 313 

Kerion 239,  256,  360 

symptoms , 239 

etiology 241 

pathology 241 

diagnosis 242 

prognosis. .  .243 

treatment 243 

Kerion  Celsi 239 

Koltun 339 

Kopskurv 256 


412 


INDEX, 


PAGE 

LaDugo  hair 25 

Lapsus  pilorum    81 

Lausesucbt 270 

Lepothrix..   293 

Lichen  menti 182 

pilaris 310 

planus 312 

scrofulosorum 312 

Lipsotrichia ..     80 

Loss  of  hair — condition  of  sub- 
jects of 108 

occupation       of 

subjects  of...  .108 
age  at  beginning,  108 
part  of  scalp  af- 
fected  109 

complicating  dis- 
eases   169 

diseases  of  scalp 

and  hair 109 

heredity  of 110 

Lousiness 275 

Lupoid  sycosis 198 

Lupus  erythematosus,    209,    268, 
304,  321,  361 

Lupus  vulgaris 190,  359,  361 

Lymphatics 30 

Maculse  cerulean 284 

Maladie  pediculaire .  .275 

Mails  pediculi 275 

Medulla,  the 22 

Melitagra 3l4 

Mentagra 18.^  245 

Microsporon  Audouini 125 

Milk  crust 314 

Mouilethrix 153 

Moniliform  hairs 1 53 

Morbus  pedicularis 275 

Muscles  of  the  hair..   31 

Mycosis  f ramboesiodes 344 

fungoide   349 

Nsevus  pilosus 350 

symptoms 350 

etiology 350 

pathology 352 

diagnosis.,   352 

treatment 352 

Nerves 30 

Nodositas  crinium 144 

Noduli  laqueati ......  156 

Oligotrichia 80 


PAGE 

Ophiasis 80,  115 

Paschkiss's  soap 53 

Paxton's  disease 293 

Pedicularia 275 

Pediculosis  capillitii 275 

Pediculosis  capitis 275,  320 

symptoms 275 

etiology 276 

pathology 277 

diagnosis 279 

prognosis 279 

treatment 279 

Pediculosis  palpebrarum 289 

Pediculosis  pubis 283 

symptoms 283 

etiology 285 

pathology... 285 

diagnosis 287 

prognosis 288 

treatment 288 

Pelada 80 

Pelade .115 

acromatosa 115 

decalvante 115 

ofiasica 115 

Phagmesis 156 

Phaiacrotes 80 

Phthiriasis 275 

Phy  toalopecia 115 

tonsurans 205 

Plan  ruboide 344 

Piedra 291 

symptoms 291 

etiology 292 

pathology 292 

diagnosis 292 

Pigment 43,  44 

Pityriasis 320 

capitis 300 

pilaris 310 

Plica  polonica 339 

symptoms 339 

etiology 341 

treatment 342 

Plique  polonaise 339 

Polls  accidentels 158 

Poliotes 63 

Poliothrix 63 

Polish  ringworm. 339 

Polytrichia 158 

Pomades 59 

Porrigine  tonsurante 205 

Porrigo 314 


INDEX. 


413 


PAGE 

Porrigo  decalvans 115 

favosa 256 

f urf urans 205 

lavalis 256 

lupinosa 256 

phyta 250 

scutalata 256 

tonsoria 205 

Psilosis 80 

Psoriasis...  .218,  268,  303,  322,  360 
Pubic  hair 35 

Rhizophyto-alopecia 205 

Ringed  hair 67 

JRingskurv    205 

[Ringworm 206,  304,  321 

of  the  beard 245 

crusted 256 

honeycomb 256 

of  scalp 205 

Root-sheath 27 

Scall,  vesicular 314 

Scalled  head 250,  314 

Scissura  pilorum 140 

Sebaceous  glands,  anatomy  of,  31 
glands,  physiology 

of 49 

Seborrhcca 268 

capitis    217 

sicca 322 

sicca  capitis .299 

Shampoo 52 

Shaving 58 

Sicosi  parasitaria 245 

Spilosis  poliosis 63 

Squarus  tondens 205 

Superfluous  hair ]  58 

Sweat  concretions 295 

Sycosis 183,  250,  331,  348 

symptoms  182 

etiolog}^ 185 

pathology 186 

diagnosis 188 

treatment 190 

prognosis 197 

Sycosis  barbae 182 

capillitii 344 

chronique 198 

contagiosa 182 

framboesia 344 

menti 182,245 

non-parasitica 182 

parasitica 245 


PAGE 

Syphilis 190,  251,  311,  323, 

332,  354 

symptoms 354 

diagnosis 358 

treatment 360 

Taches  ombrees 284 

Teigne  annulaire 2U5 

du  pauvre 256 

faveuse 206 

herpetique  furfuracee..205 

mentagra 245 

pelade 115 

tondante 205 

tonsurantc 205 

Thin's  para.siiic  disease 296 

Tinea  araiantacea 314 

asbestina 314 

barba} 245 

decalvans 115 

favosa 256 

ficosa .256 

furfuracea 314 

granulata 314 

kerion 239 

lupinosa 256 

maligna 256 

nodosa 293 

sycosis 245 

tondens 205 

tonsurans 205 

vera 256 

Trichauxis 158 

Trichiasis  180 

Trichoclasia 144 

Trichoma 339 

Trichomyces  tonsvirans 205 

Trichomykosis 205 

barbae 245 

capillitii...;..   239 

favosa 25<» 

Trichonosis  cana 03 

discolor 6) 

furfuracea 205  • 

poliosis 63 

Trichophytie       205 

sycosique 245 

tonsurantc.    ...  .205 

Trichophyton  tonsurans 212 

Trichophytosis  barbae,  189,245,331 

symptoms 245 

etiology 248 

pathology.    ...249 
diagnosis 249 


414 


INDEX. 


PAGE 

Trichophytosis     barbae— treat- 
ment  251 

prognosis .  255 

Trichophytosis  capitis 129,  205' 

symptoms.    ...205 

etiology 210 

pathology 212 

diagnosis 217 

treatment 222 

prognosis 238 

Trichorrhexis  nodosa 71,  144 

symptoms 145 

edology      146 

pathology 149 

treatment 153 

Trichorrhoea  80 

Trichosis  athrix 80 

decolor 74 

farfuracea 205 

hirsuties 158 


Trichosis  pityriasica 2Uo 

plica .339 

tonsurans 205 

Trichosyphilis  144 

Trichoxerosis 140 

Tricolorosi 74 

Twin  hairs 29 

Ulerythema  sycosiforme 198 

Verrucse 348 

Vespajo  del  caplllizio 239 

Vitiligo  capitis        ..115,  130,  i;63 

Vitreous  membrane. 27 

Vulpis  morbus 80 

Weichselzopf 339 

Wigs 56 

Yellow  hair 78 


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